Claim, Blosch, Gary M.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: Gary M. Blosch
2. Address: 857 Berkley Pl.
`
3. Telephone Number: 557 9887
4. Date of Incident: June 30th, 2006
5. Time of Incident: 4:30 P.M.
6. Location of Incident (Be specific): Basement of 857 Berkley
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.)
City water main broke, filling up the City Sewer Main and then backed up through the basement floor
drain causing extensive water and mud damage.
8. What were weather conditions like? Sunny, Warm.
9. Give name and address of any witnesses: Jef Jaeger, 2725 Oak Crest Dr.,
John Klostermann, (Sewer Maintenance Supr.)
10. Did police investigate? (If so, give names of officers.)
Police were called after street started to cave in.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
N/A
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.)
13. What other damages do you claim, if any?
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.)
N/A
15. What amount do you claim from the City of Dubuque?
$12,943.66
16. Why do you claim the City of Dubuque is responsible?
The water main and sewer mains are the property of the City which caused the damage.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
N/A
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 , 20 .
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
A~~ t2/A ~~
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 West 13th St.,
Dubuque, IA 52001. It will then be referred to the appropriate department for
investigation and to the City Attorney's Office. 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: (;(]f('r' (11. iSl(J5Ch
2. Address: (16 7 BelZKLeP PL.
3. Telephone Number SS7- 9Y.Y'7
4. Date of Incident: '3LtVIP 30th 06 '
5. Time of Incident: Lj,30 D. WI .
,
6. Location of Incident (Be specific);
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7. Describe the 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?
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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 ;?jured? (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.)
13. What other damages do you claim, if any?
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?
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17. Have you made any claim against anyone else for damages as a result of
this incident? (If yes, give name and address.)
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18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
Dated this
day of
,20 .
(Signature)
(Print Name)
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SERVPRO OF DUBUQUE
FIRE RESTORATION, MOLD MlTIGA TION, & WATER MITIGATION
Room: HALLWAY
Ceiling Height: 8'
Apply anti-microbial agent - after hours
Water extract from floor - Gray water - after business hrs
Tear out trim/base - after business hours
87.40 SF
87.40 SF
24.92 LF
Room: FURNACE ROOM
Ceiling Height: 8'
52.92 SF
52.92 SF
Apply anti-microbial agent - after hours
Water extract from floor - Gray water - after business hrs
Room: LAUNDRY
Ceiling Height: 8'
Apply anti-microbial agent - after hours
Water extract from floor - Gray water - after business hrs
51.19 SF
51.19 SF
Room: BATHROOM
Ceiling Height: 8'
Apply anti-microbial agent - after hours
40.11 SF
Room: STORAGE
Subroom 1: STORAGE2
Ceiling Height: 8'
Ceiling Height: 8'
52.08 SF
52.08 SF
Apply anti-microbial agent - after hours
Water extract from floor - Gray water - after business hrs
Room: BEDROOM
Ceiling Height: 8'
Apply anti-microbial agent - after hours
Tear out wet non-salvo gluedn. cpt, cutlbag- aft. bus. hrs
Floor prep (scrape rubber back residue)
Water extract from floor - Gray water - after business hrs
Tear out trimlbase - after business hours
149.54 SF
149.54 SF
149.54 SF
149.54 SF
58.94 LF
Room: CLOSET BDRM
Ceiling Height: 8'
2006-06-30-2339
07/06/2006 Page: 3
(
SERVPRO OF DUBUQUE
FIRE RESTORATION, MOLD MITIGATION, & WATER MITIGATION
CONTINUED - CLOSET BDRM
Apply anti-microbial agent - after hours
Water extract from floor - Gray water - after business hrs
Tear out wet non-salv. gluedn. cpt, cutlbag- aft. bus. hrs
Floor prep (scrape rubber back residne)
Tear out trim/base - after business hours
16.77 SF
16.77 SF
16.77 SF
16.77 SF
17.33 LF
Room: LNDRY CLST
Celling Height: 8'
2.64 SF
Apply anti-microbial agent - after hours
Grand Total
2,244.05
Terry Lenstra
Grand Total Areas:
2,668.00 SF Walls 803.69 SF Ceiling 3,471.69 SF Walls and Ceiling
803.69 SF Floor 89.30 SY Flooring 333.50 LF Floor Perimeter
0.00 SF Long Wall 0.00 SF Short Wall 333.50 LF Ceil. Perimeter
803.69 Floor Area 881.10 Total Area 2.668.00 Interior Wall Area
999.54 Exterior Wall Area 126.28 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
2006-06-30-2339
07/06/2006 Page: 4
,/
SERVPRO OF DUBUQUE
FIRE RESTORATION, MOLD MITIGATION, & WATER MITIGATION
Client: BLOSCH MELINDA
Home: (563) 557-9887
Home: 857 BERKLEY CT
DUBUQUE, IA 52001
Operator Info:
Operator: OWNER
Estimator: Terry Lenstra
Business: (563) 582-7776
Business: ] 044 Iowa street
Dubuque, VI. 5:00]
Type of Estimate: Water Damage
Dates:
Date Entered: 06/30/2006
Date Assigned: 06/30/2006
Price List: IADU4B6B
RestorationlService/Remodel
Estimate: REMODEL
Thisc,"imale is for the remodeling of the affected area ofthis residence.
This remodel IS NOT an upgrade, but it is to restore the affected area to the condition it was before the water damage.
SERVPRO OF DUBUQUE
FIRE RESTORATION, MOLD MITIGATION, & WATER MITIGATION
REMODEL
Main Level
Room: TVIBAR AREA
Ceiling Height: 8'
Glue down carpet
Baseboard - 2 1/4" stain grade
Stain & finish baseboard
163.38 SF
67.33 LF
67.33 LF
Room: EXTRY
Ceiling Height: 8'
Baseboard - 2 1/4" stain grade
Stain & finish baseboard
5.92 LF
5.92 LF
Room: CLOSET
Ceiling Height: 8'
Baseboard - 2 1/4" slain grade
Slain & finish baseboard
17.83 LF
17.83 LF
Room: HALLWAY
Ceiling Height: 8'
Baseboard - 2 1/4" stain grade
Stain & finish baseboard
24.92 LF
24.92 LF
Room: BEDROOM
Ceiling Height: 8'
Baseboard - 2 1 "4.. stain grade
Slain & tinish baseboard
Glue down carpel
58.94 LF
58.94 LF
149.54 SF
Room: CLOSET BDRM
Ceiling Height: 8'
Baseboard - 2 1/4" slain grade
Stain & finish baseboard
Glue down carpel
17.33 LF
17.33 LF
16.77 SF
REMODEL
07/06/2006 Page: 2
SERVPRO OF DUBUQUE
FIRE RESTORATION, MOLD MITIGATION, & WATER MITIGATION
Room: Drywall repair
Drywall repair - Minimum charge
The above entry is to repair the holes in the drywall.
1.00 EA
Grand Total
2,205.97
Terry Lenstra
Grand Total Areas:
2,668.00 SF Walls 803.69 SF Ceiling 3,471.69 SF Walls and Ceiling
803.69 SF Floor 89.30 SY Flooring 333.50 LF Floor Perimeter
0.00 SF Long Wall 0.00 SF Short Wall 333.50 LF Ceil. Perimeter
803.69 Floor Area 881.10 Total Area 2,668.00 Interior Wall Area
999.54 Exterior Wall Area 126.28 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
REMODEL
07/06/2006 Page: 3
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