Claim Van Cleve, Vernon C.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: Vernon C. Van Cleve
2. Address: 2542 Marywood Dr. Dub.IA 52001
`
3. Telephone Number: 563 583 9238
4. Date of Incident: 4-17-05
5. Time of Incident: 2:30 P.M.
6. Location of Incident (Be specific): 2542 Marywood Dr.
Dubuque, IA 52001
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.)
Sanitary Sewer back up into the basement of 2542 Marywood Dr.
8. What were weather conditions like? Cloudy & rainy
9. Give name and address of any witnesses: Shelly Rellihan, 2538 Marywood Dr.
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.)
Basement walls and flooring, furniture & clothing and other items that were soaked with the sewerage.
13. What other damages do you claim, if any? Back yard was tore up by sewer (City) truck.
Yard should be put back in original condition.
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?
All
16. Why do you claim the City of Dubuque is responsible? The sewer was flushed by City Sewer
employees - the sewer going down to the main sewer plugged up.
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 18th day of May, 2005.
/s/ Vernon C.Van Cleve .
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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: Vernon C.Van Cleve
2. Address: 2542 Marywood Dr. Dub, IA 52001
`
3. Telephone Number: 563 583 9238
4. Date of Incident: 4 17 2005
5. Time of Incident: 2:30 P.M.
6. Location of Incident (Be specific): 2542 Marywood Dr.
Dubuque, IA 52001
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.)
Sanitary Sewer Backed up into the basement of
2542 Marywood Dr.
8. What were weather conditions like?
Cloudy & raining
9. Give name and address of any witnesses:
Shelly Rellihan, 2538 Marywood Dr.
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.)
Basement walls and flooring, furniture and clothing & other items that were soaked
with the sewerage.
13. What other damages do you claim, if any?
Back yard was tore up by sewer (City) truck. Yard should be put back in original
condition.
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?
All
16. Why do you claim the City of Dubuque is responsible?
The sewer was flushed by City Sewer employees. The sewer going
down to the main sewer plugged up.
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 18th day of May, 2005. .
/s/ Vernon C. Van Cleve
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
. /1:'//1; J~ /? d/cud.c://
CLAIM AGAINST THE CITY OF DUBUQUE, Ic,Viii! ~4.M-t;A>
This written report constitutes your claim against the City of Dubuque, Iowa. You ShO~
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: VMUV'O IV C " V A- 41 e..,Lf: /t:
2. Address: 2 S;t(2. Jl1 /l-ft j """ -oc?iJ VA VtI B. ;I-:{J, S-2d7)
~~3 ~ 5:t:22~az-?A2 /
3. Telephone Number: e:::r 0 -- / tY t7
t-f _/,?v .2fX1~
'7 :. L r:7 'P r}J-
5. Time of Incident: k' 0' f
4. Date of Incident:
6. Location of Incident (Be specific): Z :;; (12 (YJ 4/h,Y v6p1/J V#- J
V'-"9zftjJ0t.j :;:;.4/- ~;:?pt7 ) '
10. Did police investigate? (If so, give names of officers.) ,if'o
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
;UO
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.)
a.~r=I1#'/lr G:J~yfs:- J FW&/#\I-:V"') F~,c:.~)~^~ .~ C2-~k0l/pr
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4- crrktf,.A ~7tftrIJ5 ~\iJA:r 0#?'t9>E .s.p4MEO Cv'//rt 7#?
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13. What other damages do you claim, if any? ~A-C/#;. Y p-il-h t.p/ A:>fo j2... C ~y<J)
1$ ~#,j/jJ)- d~1 nLv"vA,. ~~D &#(/(.//Jo tz,. 4// h;;~t /p ?
t? /1-/ &::-A-I'Y. ~v c....p p (),l IJ '0 /}/ ~ '
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?
4~~
16. Why do you claim the City of Dubuque is responsible? -r Jl15 ~&~1J,. ~.o-.:5
~2-~~J.-l~lJ ~y C-~JY d~~~ ./?~~W_'Ic~/--1#~ r'
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~C:::>' ~<.- r" b??;1I e::- D t? t# /V , c:7 ./ tr7?- ./Y}4'7;'Y c5~ 4P'~ P.Y' J ~ ~.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.WV I
.
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
/$
,
day of . ~_:_j.~)1At ,200~
~~ uC~
(Signature) 1 /
j6:iV"t7A/ C:, /(,4.tfv a~vC
(Print Name)
~._- .
L.
, .
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(Rev. 1/00 & 7/01)
Service Masters
Misc.
Bath Towels
Throw rugs
Hawkeye Sweatpants
Nike shoes
Work shoes
$2505.29
35.00
40.00
40.00
20.00
10.00
$2650.20
^ L e (? Q~t '8.A-c--~ Y -
J-" QT' 4-Atl ; /J/ OJ A I 6/// 4-'1../
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Servicemaster of the Key City
1845 Washington Street
Dubuque, IA 52001
Phone: 563-557-1488
Federal 10#42-1429160
Claim Number Policy Numb<.'r T)'pC' of Loss [)eductible
?????????
?????????
Water Damage
$ 0.00
Insured: Vern VanCleve
Home: (563) 583-9238
Home: 2542 Marywood Drive
Dubuque, IA 52001
Date of Loss: 04/16/05
Date Inspected: 04/18/05
Date Received: 04/18/05
Date Entered: 04/20/05
Price List: IADU2B4C
RestorationlServicelRemodel with Service Charges
Factored In
Estimate: V ANCLEIvE
Servicemaster of the Key City
1845 Washington Street
Dubuque, IA 52001
Phone: 563-557-1488
Federal ID#42-1429160
Area Items: V ANCLF#VE
VANCLEI\'E
CAT SEL ACT OESCRII'TION
CALC QNT\' I~Ei\IOVE REPLACE TOTAL
FCC AV + Carpet
1.00 JB 1,020.08=
FNC MN + Finish carpentry - Minimum charge
1 1.00 EA 372.82=
DMO DUMP< - Dumpster load - Approx. 12 yards, 1-3 ton of debris
1 1.00 EA 178.29+
1,020.08
372.82
178.29
Area Items Total: V ANCLE VE
1,571.19
Main Level
Area Items: Main Level
CAT SEL ACT OESClUI'TION
CALC QNTY RHIOVL REI'LA( E TOTAL
CGN
MSC
4.5
+ Clean miscellaneous items
4.50 HR
24.84=
111.7 8
Area Items Total: Main Level
Ill. 78
Room: LAUNDRY
416.00 SF Walls
560.67 SF Walls & Ceiling
16.07 SY Flooring
52.00 LF Ceil. Perimeter
144.67 SF Ceiling
144.67 SF Floor
52.00 LF Floor Perimeter
CAT SEL ACT I>ESCRIPTION
CALC QNTY RJ:i\IOVE REPLACE TOTAL
F
+ Apply anti-microbial agent
144.67 SF
- Remove Tear out and bag wet insulation
20.00 SF 0.37+
0.17=
24.59
WTR
GRM
WTR
INS
20
7.40
Room Totals: LAUNDRY
31.99
V ANCLq,VB'
05/06/2005 Page: 2
.,
Servicemaster of the Key City
1845 Washington Street
Dubuque, IA 52001
Phone: 563-557-1488
Federal ID#42-1429 160
CAT SEt (> ACT OESCRII)'nON ' .. ,
CALC QN'" REi\IO\ r IU:!)LACF TOTAL
f'--7'4"~
CLN
F-
F
WTR
GRM
F
Room: 1 BATH
385.33 SF Walls
447.69 SF Walls & Ceiling
6.93 SY Flooring
48.17 LF CeiL Perimeter
62.36 SF Ceiling
62.36 SF Floor
48.17 LF Floor Perimeter
+ Clean floor
62.36 SF
+ Apply anti-microbial agent
62.36 SF
0.29=
18.08
0.17=
10.60
28.68
Room Totals: 1 BATH
14'6"
Room: BEDROOM
512.00 SF Walls
656.39 SF Walls & Ceiling
16.04 SY Flooring
64.00 LF CeiL Perimeter
144.39 SF Ceiling
144.39 SF Floor
64.00 LF Floor Perimeter
CAT SEL A( T I)ESCI~II'T10N
CALC QNTY REi\IOVE REPLACE TOTAL
WTR EXT
I/2F
FNC B6H
I/2PF
WTR GRM
F
WTR PAD
F
WTR FCC
I/2F
V ANCLF#VE
+ Water extraction from floor
72.19 SF 0.37=
- Remove Baseboard - 6" hardwood
32.00 LF 0.29+
+ Apply anti-microbial agent
144.39 SF 0.17=
- Remove Tear out wet carpet pad and bag for disposal
144.39 SF 0.26+
- Remove Tear out wet non-salvageable carpet, cut & bag for disp.
72.19 SF 0.21+
26.71
9.28
24.55
37.54
15.16
05/06/2005 Page: 3
'"
Servicemaster of the Key City
1845 Washington Street
Dubuque, IA 5200 I
Phone: 563-557-1488
Federal ID#42-1429160
CONTINUED. BEDROOM
CAT SEL ACT I>ESCRIPTJON
CALC QNTY REMOVE REPLACE TOTAL
DOR
DOR-RS
2
ROOM>
I
CON
+ Interior door - Detach & reset - slab only
2.00 EA
+ Contents - move out then reset - Large room
1.00 EA
10.25=
20.50
64.08=
64.08
Room Totals: BEDROOM
197.82
14' 2"j
Room: HALL
469.11 SFWalls
643.56 SF Walls & Ceiling
19.38 SY Flooring
67.67 LF Ceil. Perimeter
174.44 SF Ceiling
174.44 SF Floor
56.83 LF Floor Perimeter
CAT SEL ACT DESCRIPTION
(ALC QNn' nri\lO\'E REPLACE TOTAL
WTR
EXT
1/2F
GRM
WTR
F
WTR
PAD
1I2F
FCC
1/2F
ROOM<
1
WTR
CON
+ Water extraction from floor
87.22 SF 0.37= .
+ Apply anti-microbial agent
174.44 SF 0.17=
- Remove Tear out wet carpet pad and bag for disposal
87.22 SF 0.26+
_ Remove Tear out wet non-salvageable carpet, cut & bag for disp.
87.22 SF 0.21+
+ Contents - move out then reset - Small room
1.00 EA 32.07=
32.27
29.66
22.68
18.32
32.07
Room Totals: HALL
135.00
V AN CLf/.v E
05106/2005 Page: 4
"I
Servicemaster of the Key City
1845 Washington Street
Dubuque, IA 52001
Phone: 563-557-1488
Federal ID#42-1429160
\0
>--12' 6"---i
1
t FAMILY ~ 10
::b N l::j'
1I~
Il~
12'
~
Room: FAMILY
485.11 SF Walls
759.11 SF Walls & Ceiling
30.44 SY Flooring
69.67 LF Ceil. Perimeter
274.00 SF Ceiling
274.00 SF Floor
58.83 LF Floor Perimeter
CAT SEL ACT OESCRIPTION
CAL( . QNJ'Y. I{El\lOVE REPLA( E . ";TOTAL
, . .
CLN
FCC
F
+ Clean and deodorize carpet
274.00 SF
0.27=
73.98
73.98
Room Totals: FAMILY
I
10
j
Room: CLST
146.67 SF Walls
165.17 SF Walls & Ceiling
2.06 SY Flooring
18.33 LF Ceil. Perimeter
18.50 SF Ceiling
18.50 SF Floor
18.33 LF Floor Perimeter
CAT SEL ACT l>[SCRIPTlON
('ALC QNTY RLI\IOVE REPLACE TOTAL
WTR EXT
F
WTR GRM
F
WTR PAD
F
WTR FCC
F
DOR DOR-RS
1
Room Totals: CLST
V ANCLEfVE
+ Water extraction from floor
18.50 SF 0.37=
+ Apply anti-microbial agent
18.50 SF 0.17=
- Remove Tear out wet carpet pad and bag for disposal
18.50 SF 0.26+
- Remove Tear out-wet non-salvageable carpet, cut & bag for disp.
18.50 SF 0.21+
+ Interior door - Detach & reset - slab only
1.00 EA 10.25=
6.85
3.15
4.81
3.89
10.25
28.95
05/06/2005 Page: 5
'I
Servicemaster of the Key City
1845 Washington Street
Dubuque, IA 52001
Phone: 563-557-1488
FederalTID#42-1429160
Area Items Total: Main Level
608.20
Line Item Totals: V ANCLE"VE
2,179.39
Grand Total Areas:
2,494.22 SF Walls 824.36 SF Ceiling 3,318.58 SF Walls & Ceiling
824.36 SF Floor 91.60 SY Flooring 308.17 LF Floor Perimeter
0.00 SF Long Wall 0.00 SF Short Wall 329.83 LF Ceil. Perimeter
824.36 Floor Area 900.83 Total Area 2,494.22 Interior Wall Area
989.33 Exterior Wall Area 123.67 Exterior Perimeter of
Walls
0.00 Surface Area 0.00 Number of Squares 0.00 Total Perimeter Length
0.00 Total Ridge Length 0.00 Total Hip Length 0.00 Area of Face I
V ANCLE.VE
05/06/2005 Page: 6
'I
Servicemaster of the Key City
1845 Washington Street
Dubuque, IA 52001
Phone: 563-557-1488
Federal 10#42-1429160
Summary for Water Damage
Line Item Total
Overhead
Profit
Sales Tax.
@
@
V ANCLE~E
05/06/2005 Page: 7
"
Recap by Room
Total 2,179.39 100.00%
Servicemaster of the Key City
1845 Washington Street
Dubuque, IA 52001
Phone: 563-557-1488
Federal ID#42-l429l60
EstImate: V ANCLEfy-E
Area: Main Level
LAUNDRY
1 BATH
BEDROOM
HALL
FAMILY
CLST
Area Subtotal: Main Level
Subtotal of Areas
1,571.19
111.78
31.99
28.68
197.82
135.00
73.98
28.95
608.20
2 179 39
72.09%
5.13%
1.47%
1.32%
9.08%
6.19%
3.39%
1.33%
27.91 %
10000%
V ANCLEA VE
05/06/2005 Page: 8
...
\0
Servicemaster of the Key City
1845 Washington Street
Dubuque, IA 52001
Phone: 563-557-1488
Federal ID#42-1429160
Recap Hy Category
O&P Items
GENERAL DEMOLITION
FLOOR COVERING - CARPET
FINISH CARPENTRY / TRIMWORK
Subtotal
Overhead
Profit
O&P Items Subtotal
Non-O&P Items
CONT:CLEAN-GENERALITEMS
CLEANING
CONTENT MANIPULATION
GENERAL DEMOLITION
DOORS
WATER EXTRACTION & REMEDIATION
Non-O&P Items Subtotal
O&P Items Subtotal
Sales Tax
Total Dollars
178.29
1,020.08
372.82
1,571.19
157.12 .
157.12
1,885.43
Total Dollars
111.78
92.06
96.15
119.08
30.75
158.38
608.20
1,885.43
11.66
@
10.00%
10.00%
V ANCLE/lVE
%
7.12%
40.72%
14.88%
62.71%
6.27%
6.27%
75.26%
0/0
4.46%
3.67%
3.84%
4.75%
1.23%
05/06/2005 Page: 9
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