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Claim by John_Valerie Herber
~;laam -t~~crnt Page 1 of 2 CLAIM AGAINST THE CITY OF DUBUQUE, IOWA This written report constitutes your daim against the City of Dubuque, Iowa. You should complete this form in full and attach any additional information that supports your daim. The daim must be filed with the City Clerk at City Hall, 50 West 13a' 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 Coundl. You vwll be provided with a copy of that report and recommendation. The final derision on all claims is made by the City Coundl. No employee of the City of Dubuque has the authority to make any representation to you as to whether your daim will or will not be paid. 1. Name of Claimar~ J~~n ~- V~ ler~`e I-1ex~~,er 2. Address: 'g(D -- Q (Q $ ~ • a, , 3. Telephone Number: - ,59 7 g (0 3 - S• ©~ a53 4. Date of lnciderrt: ~ ~ ~ dbb'7 5. Time of Inadent ~~ ~-- (pa,w~ 8. location of Inddent (Be spedfic}: _ ~.Tl'rYti[,/1'7 S n-t~ k`~ [„ -L ~(o ~ ~ , sf~ Sf , 7. Describe the accident or occurrence that caused injury or damage. (Give full details upon which you base your daim. If a City employee wasL involved, give the employee's name.) 1t71~ y~ C r~ti~ c, T ? ~ r~IIn 6 n / -S~ e ~ eft' I~' S '~'~ r. `- Jdl ~ ~"! '~, aL~ D4 r ~ 01 LC.d /) Y~-f~ /~~ ~ rat ~C /M[ `~T ~,P01~''a - / - QGLDr'/" ~ ,n 1, ~1? U/'~P/n u4~,.r1 ~i `721 hC! I ~Cti,D'~ ~~~ S7Z~ / ,r A e i y h ~~~ 8. What were weather conditions like? _ S l~'D~''/h ~/ P~p~"' S ~pU~. 9. Give name and address of any witnesses: ~P.f%ILfti~S fir, r~ S~~~er- C~ip o r,~ ~ a ~ ~ ~ SP, ~ ~ ~-_ '_~_ 10. Did police investigate? (If so, give names of officers.) t? - 11. WnnaslIanyone injured? {If so, give names, addresses, and extent of injuries.) lVt~ . 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.) e re~ie 13. What other damages do you daim,rf any? http://www.cityofdubuque.org/printer friendly.cfm?PageID=155 7/19/2007 Claim Form 14. Have you been compensated for any part or all of your claim by any insurance company? (If so, give name andadlIdress of insurance company and amount paid.} I~ J 15. What amount do you daim from the City of Dubuque? 16. Why do you claim the City of Dubuque;is responsible? ~~{ f.~ ~(.U D-~~ d h Page 2 of 2 17. Have you made any daim against anyone else for damages as a result of this inddent? (If yes, give name and address.} V- 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 j , 20 ®7. (~n re) -L2L.dC- l (Print Name) print this page ~ ~ yC7 ~ ~ ~r ' C ~ ~ ~' - ~' tr.~ ~ .J 'D ` ~Tl ~ F~ CU O .c- http:/Iwww.eityofdubuque.org/printer friendly.cfm?PageID=155 ~/19/2Q07 Maims against the City Page 1 of 1 When should 1 file a claim? If you have sustained an injury or damage for which you believe the City or one of its employees is responsible, you may file a claim against the City. How do 1 request a claim form? In order to obtain a daim form, please centact or visit one of the following City offices: City Clerk's Office, City Hall _ 50 West 13th Street, Dubuque, IA 52001 (563/58&4120), or City Attorney's Office, Harbor View Place - Suite 330, 300 Main Street, Dubuque, IA 52001 (563/583-4113). Once the daim form has been completed, please return it to the City Clerk's Office at the above address. Can I send in additional information with the claim form? Yes. It is recommended that you send in as much information as possible with your daim form in order to expedite the investigation of the daim. This includes, but is not limited to, estimates, receipts, medical bills, pictures and any other information you feel may be relevant to your daim. It is also recommended that you send in copies of these items and keep the originals for your records. What happens after I file my claim? Once a daim has been received and file-stamped by the City Clerk, it is forwarded to the City Attorney's Office for investigation. Claims involving personal injury or substantial property damage will be forwarded to the City's claims agency for investigation. You will receive a letter from the City Attomey's Office indicating that your daim has been forwarded to the claims agency. This letter will also contain the claims agency's contact information. A claims adjuster will then contact you regarding your daim. At that point, any questions regarding your daim should be addressed to the claims adjuster. All other claims will be forwarded to the appropriate City department for investigation. After speaking with employees and consulting department records, the department manager/supervisor vrill make a recommendation as to whether the daim should be approved or denied. Based on that information, the City Attorney will then make a recommendation to the City Council as to whether the daim should be approved or denied. If the City Attorney recommends that the daim be denied, you will receive a copy of the department managedsupervisor's report along with the City Attorney's report to the City Councl. If the City Attorney recommends that the daim be approved, you will receive the City Attorney's report to the City Council as well as a release form to be signed and returned to the City Attorney's Office. These are only recommendations. It is important to note that the final derision on all claims is made by the City Coundl. No employee of the City has the authority to make any representation to you as to whether your daim will or will not be paid. If the City Coundl approves the claim for payment at its City Coundl meeting, a check will be mailed to you provided the City Attorney's Office has received your signed release form. What if my claim is denied by the City Council? The City Coundl makes its determination at City Council meetings, which are held the first and third Monday of each month. We recommend writing a letter to the City Coundl indicating why your daim should not be denied and any additional information that you have to support your claim. It is not necessary to appeal the City Attorney's recommendation for denial of your daim before the City Coundl makes its determination, however, you may do so. You are invited to attend the City Coundl meeting when your claim will be derided; however, your attendance is not mandatory and you still have the right to appeal the City Coundl's decision any time after it has been made. If your daim or appeal is denied, you have the option of filing a lawsuit in a court of appropriate jurisdiction. How long do I have to wait before my claim is resolved? The length of time it takes to investigate and resolve a daim depends Largely on the nature of the daim and the amount of damages involved. Some claims may take a few weeks to restive, while others may take longer. If you wish to check on the status of your daim or if you have any questions or concerns about the process, contact the City Attorney's Office at 563/583-4113. How long do I have to file a claim? You may file a daim at any time. However, if your claim is denied by the City Coundl and you wish to file a lawsuit, you should be aware that state law may limit the time in which to file a lawsuit. print this page http://www.cityofdubuque.org/printer friendly,cfm?PageID=i54 7/19/2007 4 - ~ ~N~ ~~~ C-OMPRESSOR ~~ t ~ DATE -•~ ~~ ,$1" i - tt~ ~7 !! ~~ CC f t"1?_~ bCERPE~i Bt_1/[?. • L./SJ4JV~~[:_~ iA52001 HEAR_-- --..--- ~ SI ~ ----- -- r'- ° 5 ' - - - -- --- - ---- - __- Fh': ~^3-588-2023 RAX: 563-556-8422 DATE ORDERED ;. VGLTS ~_ [~AM1 S . _ • -j CHECKELE{"1~CALCONNECTIIX~IS _ ___ __ ____. _ taY~Lae~°xIE 4.: ~`~vW7aa~.w~l'?SG~"wO.~a"CCTI DATE SCHEDULED "-'t OII LE'i1~EL & CONDITION I ~ -~` w ' NAME ` CONDENSER COIL -' ~ ~ " ~„~ _ =- PHONE ~ ?C ;c f ! INSPECT OQIL.&FIN CONBI'tION __~ STREET ~ . , CONDENSER~FAN'`• ' -- ~ ~ -~~ ~ ~~='-°- WORK OR DAYTIME PHONE '-" VOLTS -..: ~[I AM S I ~ _ CITY STATE ^•~"~ ZIP ~. ~ ^ CHECK-E1-ECTRICAL CONNECTIONS ' •^~ 1 ' -f DISPATCH 71 r .-. , ~ ry ifQSPECT PROP FOR CRACI~S ~ MAK R MODEL SERIAL NUMBER ~"' `' « • ~ WARRANTY • ~ ~_, ^ I ^ CONTRACT BLOWER MO TOR + ' • CONTRACT _ VOLTS '~~ ^AMPS ~ ~ ~ ~ ~ ^ NORMAL ~ ~ ~ - ~ ~ EFFICIENCY ~^ CHECK ELECTRICAL CONNECTIONS - ' ' ~ -. ~ UOB ^ RES. ^ COMM. f [~„IAISP~GT P.ULL,EY,S i~.~ELT .. LOCATION ^ ~` INSPECT MOTOR BEARINGS ' ;~ ". ~ `' ' > ~ • • ~ ^ ~ • (, BLOWER WHEEL OK?+j~Y > N ~ ~ • ~ • ~ ~~ INSPE'C`i~ OIL $ faIF1~CONDITION °•- ,'. -^ 1 -` C ^ u. ,,, .: , ~, 4 'tis ~.r.' ,~~` ` ~ ~ jdECK REF'N BUL~`GQNDITION ^ C ~ ~- , I •'8 LOCATION ^+,~ -~ i ` „ , ' ~' ~ ,- CONDENSATE '~ ~ ~ - ~ - INSPE?CT~~AtN'PAN ~ . ~ ` R4 -g ~ rt. + ~ er, i •,A ~ •-, • ^ 1 ^,-INSPECT DRAINTCI4IES.... 1 :~ ,, ~ ~ ~- ~ ~ ~ {~ ' AI ILTRATION "" TECHNI . . cIAN . ' • # r ^~ ..~ SPOSABLE WASHABLE ^ ELECTRONIC ~ ~ • • ^ SIZE QTY _ ^ • • SIZE QTY , GAS / ~ D C7 [~ INSPECT FUEL SUPPLY PRESSURE INSPECT HEAT EXCHANGER - CHECK SAFETY CONTROLS M$PECT FUEL PRESSURE ~ ~ ~ ~ ~ ~ • ^ INSt~ECT HEAT EXCHANGE 0 CHECK $ ETY CONTROL ,• ' ~ • . ~ . ° ~ . INSPECTOIL LTER ~ ' INSPECT NOZZI ~ -- ~ - • ' •- - "' ~ ~ ' ~ - ~ ~ - - ' ' ~ ~ - • , • BOILER ~ ~ - • • • - • • CUSTOMER REQUEST: TOTAL O7}IEq , INSPECT~MPING S EM - - ~~~ [~ INSPECT LOW WATER CU FF SUB-TOTAL INSPECT EXPANSION TANK ~ ~ • • • • TECHNICIAN MSPECT SAFETY CONTROLS ~` y " ~ REFRIGERANT O O O E N D SIGNATURE: DIAGNflSI'IG (; ; ~i, ('~ CTRIC H -T 'T W ~ "`~ ^ INSP STRIPS ' R E ~ O OUT OR Q I I REPLACED ? ves No ~ I _ ~ ~ ^ ~ ~ TAX I { ~ : : ~ RECOVERED? ves OTY. No I - J '' ' ~ I CT FUSES ` ~ ~ ~ DISMANTLED? O O P I HAVE THE AUTHORI ORDER THE ABOVE WORK AND DO SO ORDER AS :OUTLINED ABOVE IT IS AGREED THAT THE SELLER WILL RETAIN TITLE TO ANY • ~ O CHECK SAFETY CONTR THERMOSTAT ~ R ©RECYCLED? I O ves O OTY. Ho ves No M E REFRIGERANT DISPOSAL EQUIPMENT OR MATERIAL FURNISHED UNTIL FINAL AND COMPLETE PAYMENT YS MADE, AND IF SETTLEMENT IS NOT MADE AS AGREED, THE SELLER SHALL HAVE THE i ~ /"~ ~ ~ ~1 ' I ~~ / N RIGHT TO REMOVE SAME AND THE SELLER WILL BE HELD HARMLESS FOR ANY V d CHECK OPERATION -CALIBRATE E ©RECLAIMED? O O," OTY. T © DAMAGES RESULTING FROM THE REMOVAL THEREOF. , ~ ; • • • ,;LEVEL ? ONING E R RETURNED TO ves rio OWNER'S INITIALS MP~RS INS ECTACTUATORS& D TTTfrf(~ SYSTEM? ~ ~ QTY AUTHORIZED SIGNATURE R -. ~ s / ~ . CC or CHECK AUTH. # O INSPEC ~ ECTK)NS ' ~ ~ 4 N T NON USEABLE O ves ~ No QTY. ~ / THE ABOVE ORD D WORK HAS BEEN COMPLETED AND I ACKNOWLEDGE RECEIPT O _ ""~ r..w ~„r X /` ~ F MY COPY. / / -iRlS P CT OVERALL OPERATION E DISPOSAL ves No DATE ,e ~-,, 0SI~14I2E~7? F13; ~9 ?195837F~6i TOTAL °LLIMBINa AIJD D TOTAL PL1JNlBtNG ~ HEATING DON JAGQU I NOT 5 MAlN STREET DUBU4U~, l01NA ~O1 BILL TO JQHN HERBER 8637 HARVEST LANE DUBUQUE, IA 52003 PAGE 01 In~roi aATI~ Irrvcxce ~ ~ r, 7!271200? !157?8 P.O. NO. TERMS QUE DATE PROJECT JOB OISCRlPTI~hI WO 736989 7/2712007 856 W 3RD ~ pESCRlPTfON QTY RATE Rk1EE~ri 42V40S - 40GALLON LOBOY NG 1 397.05 3y7.0 T WATER NEATER SERiA1. #0707504864 6 YR 0.00 0. T 3/4 MALE ADAPTER 3 2.89 $.6 T 314 ~'. LINE S 2.22 11.1 T 3,`4 X 1I2 REDUCER 2 2.29 ~ 4.5 ~' CORY -OVER TIlNE 97.50 97. T CORY 2.5 65,00 1b2.5 T N.A,TE 1.25 65.00 ~ 81.2 T 'DAMAGE DO TO 1;LOODWG IN BASEMENT SALES TAX 7.00% ~ 53.3 i I i i I i Yotai ! ~sas. _ __ _ _ 02,+'04!2007 93:3'? 31x583705? TOTrii_ =_IIMBIIda ~;I~IL~ FJ F'Ar~ TF~TA,L ,P,Lt1MBINC & HEATING s .rKAm sT nv,~uQtr~', ~ saaet-~~aa s63-ss~-a3~~ S63-S8;-7Q67FAX JULY 33, 244'1 JOHN & VA.LERLE HERBER 8637 HARVEST RD DUBUQUE, LA 52003 R.E: 866 W STH P~.tQYUSAL WE AGREE TO SUPPLY' AND Il~iSTALL THE Ft~T..Lt)WING: 1-HONEYWELL. S$b 1GN~TION MODULE X152.$3 1 - VR$d4M GAS VALVE 185.SS t - PYLOT ,ASSEMBLY 38.1 L LABUR 260 Sb36.79 TAX 44 7 FOR THE SUM OF: S68l.3fi PROPOSAL AGREEIVLENT .NAT IRF PATE -1 1