Claim UFCW 421 John Honeycutt
SEP-09-05 FRI 10:28 AM UFCW431 FAX NO, 5633238763 p, 02
. ~EP-~9-2005 10: 18 FELDERMAN* 5635884f.14 P.04/05 rt\ J(ft
CLAIM AGAINST THE CITY OF DUBUQUE,-IOWA' 1/q( 0 5 ~
This written report constitutes your claIm against the City of Dubuques Iowa. You should G lJ'$
complete this form in full end ettaeh any addition_I information that 8UppartS you~ ~I~im.
The Claim 'Must be filed with the City Clerk at City Hall, 50 W. 13th St" DubuqulI, IA 52001.
It will then be referred by the City Counctt tc the appropriate department for Investigation.
Once that Inve&tlgation is completed, a report and recommendation will be submitted to the
CIty Council. You will be provlded with a copy ot that report and recommendllUon.
10. Old pollee lnvestlgate? (If 80. give names of officers.)
NtJ
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11. WeB anyone Injured? (If so, give namBS, addresses, and extent of lnjurl.s)~
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SEP-09-05 FRI 10:28 AM UFCW431
FAX NO. 5633238763
p, 03
SEP-09-2005 Hl: 19 FEL.DERMAN* 5635884214 P. 05/05
12. Was any dam~gfJ done to property?' (If 10. de"rlbe property and the extent 0' dlmagoe.
Attach estim8tes of damllges or descrl~ basis for ascertslnlng extent afdllmllge.)
(!()JuiAiL-c:k"jlJ4) ~u~me~~ tJ;J 1.1)/ - ,/:)JL)
f)A-m"l~ ~ P~~~l k T
13. Whet o,ther damages do you claim, If any?
IvIJ
14. Heve you been compensated for any part or all of your claim by any insurance
company? (If so, give name and 8dd~ess of Insurance company and amount palcl.)
AJe)
15. What amount do you claim from the City of Dubuque? $1, ~13... t)o
1 e. Why do you clelm the City of Dubuque Is responsible? & ~ to AJ
. R~~-t ~,)ew ~ 1.r,-...-eJ ,~ ~11J9T~ /J?J.I)
UJ.l'~{) ~tJL )tJT B. ~r. a...x.J1<!-4 a.~7i ~~~ ~
17. Heve"You made any claim against anyone else for damages as a result of this incident?
(If Villi. give name and .ddre....), AId
I ,
18. it th~ answer to Question 17 1& yeli, have you receiv'ed ,any payment from that source,
and If so; in what amount? ' .
Deted at DubUqu.. Iowa this;, q
. '~ .
dillY of a. ~;'h '. 20 a.r'.
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~),; 14~~~ .
, (Print Na-me) /11i w 3~ff
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(Rev. 1/00 It 7101)
TOTAL. P.135
.~ Paving & Parking Lot Service
4485 Dodge Street
Dubuque, Iowa 52003-2601
"Paving The Way For The Tri-States"
Phone (563) 556-6231
Fax (563) 588-1240
JlroposaII <!Contract
www.apelinc.com
apelpark@dubuque.net
lan/lack Feldennan
1179 Iowa St.
Dubuque, IA52001-
Job#:
5776 ID: F eldenna
1111 Bluff
(563) 557-1465
8/23/2005
Location
Home
Business
Cell: (563) 213-0635
Fax (563) 588-4214
We hereby submit specifications and estimates for:
NEW ASPHALT LOT - approximately 2,966 sq. ft.
Remove old asphalt up to 3.5" to 4" thick.
Regrade and compact existing base material.
It appears that the base is solid and does not need excavation or additional base stone. If excavation
or base stone is needed, it will be extra and will be charged on a time and material basis.
Furnish up to 30 ton of base stone fro shaping of lot.
I. Pave lot with 2.5" of new asphalt.
I. $4,893.00
II. OPTION: Pave lot with 3. of new asphaft.
II. $5,343.00
WE PROPOSE hereby to furnish material and labor - complete in accordance with above specifications, for the sum of:
To be paid in full upon completion of work.
dollars ($
).
Note: This proposal may be wit~awn by us
if not accepted within days.
Signature
Daniel 1. Apel
ACCEPTANCE OF PROPOSAL: Acceptance of this Proposal includes Acceptance of
All of the Additional Agreement Provisions of the Reverse Side. 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.
Signature
OWN ER/PU RCHASER
Signature
Date of Acceptance:
OWNER/PURCHASER
Please sign and return the white copy to our office.