Claim Gibson, MichaelCLAIM AGAINST THE CITY OF DUBUQUE, IOWA
This written report constitutes your claim against the City of Dubuque, Iowa. You should complete this form in full and attach any additional information that supports your claim.
The Claim must be filed with the City Clerk at City Hall, 50 W. 13th St., Dubuque, IA 52001. It will then be referred by the City Council to the appropriate department for investigation. Once that investigation is completed, a report and recommendation will be submitted to the City Council. You will be provided with a copy of that report and recommendation.
THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE OF THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1.Name of Claimant: Michael Gibson
2.Address: 1185 S. Grandview Ave., Dubuque, IA 52003
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3. Telephone Number: 557 9617
4. Date of Incident: 10/08/04
5. Time of Incident: ?
6. Location of Incident (Be specific): 1185 S. Grandview, Garage Door was damaged;
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give full details upon which you base your claim. If a City employee was involved, give the employee's name.)
Hunk of Wood flew out of grinder and punchered a hole in our garage door. Steve Pregler notified us. 589 4298
8. What were weather conditions like? ?
9. Give name and address of any witnesses:
Steve Pregler
10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No
12. Was any damage done to property? (If so, describe property and the extent of damages. Attach estimates of damages or describe basis for ascertaining extent of damage.)
Hole in middle of garage door, estimates included.
13. What other damages do you claim, if any?
None
14. Have you been compensated for any part or all of your claim by any insurance company? (If so, give name and address of insurance company and amount paid.)
No
15. What amount do you claim from the City of Dubuque? $540.00
16. Why do you claim the City of Dubuque is responsible?
City of Dubuque was removing tree stump on Indian Ridge. Steve Pregler witnessed event.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
No
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?
Dated at Dubuque, Iowa this 26th day of October, 2004.
/s/ Christine Gibson
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
This written report constitutes your claim against the City of Dubuque, Iowa. You should
complete this form in full and attach any additional information that supports your claim.
The Claim must be filed with the City Clerk at City Hall, 50 W. 13th St., Dubuque, IA 52001.
It will then be referred by the City Council to the appropriate department for investigation.
Once that investigation is completed, a report and recommendation will be submitted to the
City Council. You will be provided with a copy of that report and recommendation.
THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE
OF THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO
YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant: fJ1 I t J-f 11 E L ~ I ¡j j'tJ Iv
2. Address: ¡If'S- S, bJe.;1A.1/..1 {//¿t<.J /tVi::-:'
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3. Telephone Number: 557- 9 ~ I 7
4. Date of Incident: /0 /tJ J? It? ¥
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5. Time of Incident: ?
6. Location of Incident (Be specific): /ltf5' s, bÆ/1Æ/lJ 1// ¿-~/L..-I
?;/f)!/'lb[ LJ¿:r?"£ lo/fS ¿}/J-/:?/ /7 6é-/J
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon which you base your claim. If a City employee was involved, give the
employee's name.)
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8. What were weather conditions like? I
9. Give name and address of any witnesses:
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10. Did police investigate? (If so, give names of officers.)
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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12. Was any damage done to property? (If so, describe property and the extent of damages.
Attach estimates of damages or describe basis for ascertaining extent of damage.) .
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13. What other damages do you claim, if any?
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14. Have you been compensated for any part or all of your claim by any insurance
company? (If so, give name and address of insurance company and amount paid.)
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15. What amount do you claim from the City of Dubuque?
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16. Why do you claim the City of Dubuque is responsible? c:.1 TV Ór P¿l',/fit' c1 é/¿;'-
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17. Have you made any ciaim against anyone else for damages as a result of this incident?
(If yes, give name and address.) ".v ()
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?
Dated at Dubuque, Iowa this
d. ~ day of
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(Signature)
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(Print Name)
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(Rev. 1/00 & 7/01)
Overhead Door Company Of Dubuque
Division of Cedar Cross Door
1040 Cedar Cross Road
Dubuque, IA 52003
Phone: 563-582-3020 / 800-395-3839
Fax: 563-588-9069
The Genuine. The Original.
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Proposal #: 1-6094
PROPOSAL SUBMITTED TO: Date ¡Attention
Chris Gibson 10/12/2004
STREET Job Name
1185 S. Grandview Chris Gibson
City State l~iPcode Job location
Dubuque IA 52003 Dubuque
Phone Number Fax Number Job Phone
557-9617 557-9617
FURNISH AND INSTALL:
1 - 18' x 21" #124 intermediate section. = $325.28
Estimate to paint door = $214.00
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We hereby propose to complete in accordance with above specification, for the sum of:
Signature /Ý {¡ '7~/ (h~¿Æ
f/ Direct Dial:
TERMS AND CONDITIONS
Payment to be made as follows:
Prices subject to change if not accepted in 30 days.
BY OTHERS: Jambs, spring pads, all wiring to motors and control stations, unless otherwise stated above, are not included.
Purchaser agrees that doors shall remain in Seller's posession until paid in full. In the event Purchaser breaches or defaults under
the terms and provisions of this Agreement, the Purchaser shall be responsible for the costs of collection, including reasonable
attorneys' fees. The Seller shall be entitled to full and final payment on the Purchase Order. There shall be a 1 1/2% service
charge per month for all payments due and owing after 30 days, (Agreements are contingent upon strikes, accidents, or delays
beyond our controL)
ACCEPTANCE: Terms, Price, and specifications on all pages of this proposal are hereby accepted and the work authorized.
Purchaser:
Signature TiUe Date of Acceptance
Page 1 of 1
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DUBUQUELAND OVERHEAD DOOR CO.
14628 Highway 20 West
Dubuque, Iowa 52003-9244
Phone (563)556-5702 Fax (563)556-5703
Proposal Submitted To
Chris Gibson
Address
1185 S Grandview
City. State. and Zip Code
Dubuque, IA 52001
Phone
557-9617
Fax
Job Name
We hereby submit specifications and estimates for.
Furnish and Replace
1- IB' x 21 "x I 3/B" Model S38FM
Wood Flush tounge & grove intermediate section
Installed:
$ 303.88 Tax Included
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Note: All wiring and pad work done by others.
Date
October 20, 2004
We Propose hereby to furnish material and labor-complete in accordance with above specifications. for
the sum of:
Payment to be made as follows:
50% Down payment with signed quote required to order
Authorized
Signature
All mater'" Is guar<mteed to be as spedfied. All work to be completed
;n workmanlike manner accorðmg to standard practices. IVr¡
alte<'ations or de,,",tion from abo"" specifications ;~ """" dwge
over and """'" the estimate wi" be executed. and wi' become """"
chacge o""r and abo", the estimate. All agreements contingent upon
strikes, accidents or delays be)Oßd our control. Owner to carry ewe.
tornado, and other necessary insurance. au.. w<><keß "" fully ~
by Workman's Compensation Insunnœ.
Acceptance of Proposal- The above prices, specifICations and conditions are satisfactory and are hereby accepted.
You are authorized to do the work as specified. Payment will be made as outlined above.
Date of Acceptance Signature
Note: Due to the volatility of
valid for only 30 days.