Claim Small, Donald "Wayne"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: Donald "Wayne" Small
2. Address: 2593 Crescent Court
`
3. Telephone Number: 556 8220
4. Date of Incident: 10 7 04
5. Time of Incident: 1:00 A.M.
6. Location of Incident (Be specific): In the street
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.)
Water
8. What were weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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.)
See Estimate attached
13. What other damages do you claim, if any?
Water damage
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?
$1665.79
16. Why do you claim the City of Dubuque is responsible?
It's the City Water Main
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 16th day of December, 2004.
/s/ D. Wayne Small
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
I"~ ('I'I'
CLAIM AGAINST THE CITY OF DUBUaUE;IOW¡~Ý'jjj:~
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: ÞoAla.i-.ð "Wa'ldf: f' SinaLL
2. Address: .2593
e"'e~c.!3Jr/T {ßo<l,¿j
3. Telephone Number: :;,-,ç&,- ~ ¡}.. ;; 0
4. Date of Incident:
/0 - 7- (Ii
5. Time of Incident:
;,'00 /9,010
6. Location of Incident (Be specific): (11' , ^, e -7/V'
The
STteee/
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon which you base your claim. If a City employee was ilivolved, give the
employee's name.)
i:/.) /l ,/,6. J(
8. What were weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
12. Was any damage done to property? (If so, describe property and the extent of damages.
II.ttach estimates of damages or describe basis for ascertaining extent of damage.)
~
.5ee.
e5'T/I'J1Q/~
c{/Ta..C'.heJJ,
13. What other damages do you claim, if any? uJ /I r £ R
~ f) /l Æ' 1'1 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.)
No
15. What amount do you claim from the City of Dubuque? :J ! IR (P ':'-, 7 9
¡
16. Why do you claim the City of Dubuque is responsible? .:::r.¡:> ¡he-
c.;Ty
IR)aTeR....
miL/I'I.
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, inwhat amount?
Dated at Dubuque, Iowa this j ¿. d1.
day of Decem¡:}e¡¿
,20EL.
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, (Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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Support Our Troops - Remember Our Veterans
T31O6
Locally'Owned ánd Operated
PAUL HERRIG
PLUMBING, INC.
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P.O. Box 1533. Dubuque, Iowa 52004. Phone 563-552-1828
. TV Camera Inspection & Video Recording
. High Pressure Water Sewer Cleaning. Electric Sewer Cleaning
CUSTOMER'S
ORDER NO.
DATE /JI/;;-
20~
/vA r~f!! Srn.A-<"(
35'73 Cí.".....;:r C~""., ~.!J--
-::.)(.- ý.Jlc.- ..s.~
~g~~':s THE PROBLEM I FOUND AN~~X5~OOGED BY: ~'~~'~~"""""""""""""$
DO Sltub'nkor shower OOgfoodrease ~' tub"""""""",.....""",."""",$
0 toilet Opaperorsanitaryprodu ¡.t1Oi1et...."""""",."""".."""" $
0 laundry I washer lines 0 hair I, $ ;¡ Y "'..
~fIoordrain Olin! 1 IIoordtT"""""""..""",
0 septic tank line gtree.'oots ~ ~""""""""""""""""$
~nsewerline uforetgnobjed".<'<",:;..,..J,¡,....-. .
tJ other ~ sludge . t Ime"""".""""""""",$ is<'
DO soap residue main sewer""""""""""".."V2?
other ",.
sf? 7. -
NAME
ADDRESS
TOTAL FOOTAGE CLEANED:
~NlVES USED
? ~,.y
$ /3?J
JOB DESCRIPTION AND REMARKS:
CUSTOMER SIGNATURE
$
1"7
TOTALJJO. -
PIEÞa: PAY F1U.11HS tMXE
,(]. ¿?,l, S"7t.-
OPERATOR SIGNATURE
A service charge of 11/2% por month (18% porannum) will be charged to all accounts past
30 days, Costs plus roason- attorney - to be added in case of suit for collection.
¡Latham WATERPROOFING
Inc.
2337 Harvest View. Dubuque, Iowa 52002 . (563) 556-8880 Fax (563) 585-1020
f I " ,
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RE:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
- - (10)
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(11)
(12)
/0-2-- 7- ( Y
Install drain system at A!::o"vJ/
1ft (d7 JI-<>
(Q...-- Jack Hammer and remove old concrete
~ Dig drainage ditch and remove dirt
(4--1ñstall drain tile and cover with gravel
{tV Replace concrete
(4--' Install sump pump ftstI"mp liner, '-
() Cement coating of limestone walls ~/,
(-4-- Materials and labor are included
(¿)..- Materials are: ~crete ( '11frain tile
fflravel (~tic pipe
Other
;/
(L}6ump pump
~ump liner
( )
I
WARRANTY
\,. Sump Pumpsl; Covered uQqer a separa\e fa9t'?ry warr,anty, We,w¡J1 iI:l$taU
without charge for period of f:¡.ctory '-'{arranty, Latham is not responsible for
any damage in event sump p¡Úhp fails:
2. Limestone Walls - Cement coating limestone walls has a five (5) year warranty
for seepage within the stone itself. There is no warranty covering moisture due to
condensation or water between the wall and floor,
3. Wall Cracks - One (1) year warranty on water seepage from,cracks repaired by
our company, Not available on cement block walls, Warranty is Void if area has
been damaged by someone else, ,
4, Inside drain tile - If any failure in system (except sump pump see #1) due to
flaws in workmanship or materials is reported within ten (10) years of installation
-- will be repair!1 ðithout charge, For the balance of the time of the warranties, the
warranties are automa~lIy transferred to the new property owner. Exceptions-
I Cement block walls - After five (5) years there will be a service charge to clean
out plugged blocks, 2 There is no warranty expressed or implied tor any damage
to real estate or personal property as a result of any flaws in workmanship or
materials, 3 Warranty not ~overed during flood or national disaster. 4 In some
areas drain tile may~obb plugged due to soil conditions Latham is not ,
responsible for the replacement of drain tile or damages due to this condition,
(q'
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The above to be completed for sum of $ (3> >é), ',--
>,
PAYMENT - Payment is &lie upon completion. If not paid at completion, balance
shall occur at the interest rate of 18 annually,
Sincerely,
Latham Waterproofing
Accepted
By: f 146Þ,~