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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 ` 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) <>, ~ 'j':/ '. :/ --;',"' /, 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::-:' ¡}¿f l3ü () t( c', :¡. /j s.;?aJ 3. Telephone Number: 557- 9 ~ I 7 4. Date of Incident: /0 /tJ J? It? ¥ , / 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.) H{¡,u!( () ¡: wad () -/1 E Iv Oil T úF 6;2IAJIJ¿~ /lIJIJ It/tV Cf/t;A3 éb /f f/¿;¿¿- IN O¿¡¡¿ c;',J1/2./J{;¿-- ¡Joe'/( , <;T[I/Ç /ÆE6¿¿j¿. Þ(/1¡,í-¡c-/) ~s, :;?;l- '},j7? 8. What were weather conditions like? I 9. Give name and address of any witnesses: S'TE/I¿-~ /J!.EbL¿/'ê , 10. Did police investigate? (If so, give names of officers.) ,(/(J 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). ,VÔ 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.) . !fó¿¿ IN /J!/)Jf}¿£ óF b/TA:I/J-6¿;- , ém ,41)j T[)' 1ft> CLq,cJ/-/:J ß cJ 0 /ê... 13. What other damages do you claim, if any? ,i/ Ó A/ ¿::- 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.) ,,(/0 15. What amount do you claim from the City of Dubuque? ~s-#./ ðD 16. Why do you claim the City of Dubuque is responsible? c:.1 TV Ór P¿l',/fit' c1 é/¿;'- , . ¿¿¡/IS k(;-~(/'¡/Iß/b ;;!c¿:; S/?r/1/,þJ£ JÆJ,()//1/1-/ £/Ø6é-~ 5TEI/(Ç ¡O1f(;',6(é/é' ú/¡Î4/!:;SSt::-/:J £-)/[/1/1 , 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 ~d~ ,20Ø, (!/~d' &~ (Signature) (2/1 d / S' // d/ ¿ - /, / ~ S¿J/J (Print Name) ,'.' t11 L' (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. ~~.~ 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 5J7 J% 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 ~ropo~a( 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 ~)..!/H.f:' f./k"'~ ðNf.-¡ --------- ,,11t!, (V - !i?7,J'f 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 InsunnÅ“. 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.