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Claim by Michael KochBARRY A. LINDAHL, ES CITY ATTORNEY MEMO To: DATE: RE: Claimant Michael Koch Mayor Roy D. Buol and Members of the City Council April 5, 2007 Claim against the City of Dubuque by Michael Koch C7 ©~ c ~ s~ ~O D 0 -.., a -v a z N Date of Claim Date of Loss Nature of Claim 04/03/07 03/26/07 Property Damage ',~~. ~7 rn This is a claim in which the claimant alleges that a city sanitary sewer located near his residence of 2585 Knob Hill backed up, causing water damage to his basement. This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa Communities Assurance Pool. BAL:tIs cc: Michael C. Van Milligen, City Manager Jeanne Schneider, City Clerk John Klostermann, Street & Sewer Maintenance Supervisor Michael Koch OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944 TELEPHONE (563) 583-4113 / FAx (563) 583-1040 / EMAIL balesq@cityofdubuque.org ,,~ e:~e ~7~~,~,7 /'( i +r . _ f CLAIM AGAINST THE CITY OF DUBUQUE, IOWA ~~ni~~ K' 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 submit#ed 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: %/1 i<~t ~ ~ / ~~ 2. Address: ~,~. 3. Telephone Number: (_l ~--~~ -~~~~7~ ~y~~ 4. Date of Incident: -3/ ~~/~ ~ 5. Time of Incident: ~~f~~ v--~~~~ G ~ ~4~':~`Gx~sxG ~°~y 7-~c::~ ~~ gyn. 6. Location of Incident (Be specific): ,~ ifs ~ ~ ~~ ~ ~~/v r.~ ~-.:~'r~z~ hs GZyuY ~.5~~~ rv~ rl ~-Cr'r~ c7 CI r Pee _3 ` 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.) / 1 r~y 7.~G~ ~./'1~< ~^ // ~ ~ i / ( - Ty ("r^t'co_ ~..clnrr F 1' Gc~a 1c~rt il!'tc ~v'rr a. ( ~ SPy,,Z-.~ > 7 ~ ~~ysp 1 ~ ~ 8. What were weather conditions like? ~~~~ ~ , (~ I~ ee r- 9. Give name and address of any witnesses: Tc-f~ 13.-;h, ~~ f= ' /f1, <~d~l ~r /'Y( .S / i' ~> i'l ~% ', i ~' ~) Yl l \ I ~.S ~f ~- lb l li. /7 ~. J / /mot' ~~C' l/ 10. Did police investigate? (If so, give,. names of officers.) J~~ n .,,~ c ~ 11. Was anyone injured? (If so, give names, addresses, and extent of inj~i). ~ `~ ,~ o ~ ~._.~._~ D ~ N ~ ~~ ~! ~• ~I / ~ rf ~ XC G /`T 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.) v. / fS bCI.SC A~t'rv'' 174r ~~lC~s' ~~n ~~~rr gf~."•~a/J ~ L' K .~' / P4<~1i~~S /~'!4 ~E'rc rc /J l~/."/!l YC•~S ~D5~.3' ..,-.~l'it1 ~.~..~.. _..~~~ .~-~.5 ~ Li~r`u~r~j/r y.__ V'u L> Pv^ ~,. ._._. ... _ t 13. What other damages do you claim, if any? _- ..5~'tr-r;c~ ~~s fP,- ~~ v 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.) ~/7 c 15. What amount do you claim from the City of Dubuque? ~~~~,-~X~z .~/~ mow, ~~. 16. Why do you ~lairrt the Gity of Dubuque is responsible? ~ t' ~~ ~7f beck ~~~-~ _. _ _ v - (~Liy.Sc'C~ ~/ (,/j~ 9d/ratf y7/F3~~Yi.:~a-s Jvt /'~ l r ~y .~~ ~jl /vr ,lf7~i Ve t~ Vt ~ fy . 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) u 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 ~~ ~t ~ day of f~~y,-~ ~i 20 c 1 . ~~, CY~, ~~. (Signature) (Print Name)