Claim Jorja's Resturant & LoungeCLAIM 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: Jorja's Restaurant & Lounge
2. Address: 890 Iowa
3. Telephone Number: 563 557 9224
4. Date of Incident: Not sure of exact date - late Oct. 2001.
5. Time of Incident:
6. Location of Incident (Be specific):
Under dishwasher area in the restaurant
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.)
When my Water meter was replaced for Jail project putting in and taking out straight pipe moving of pipe broke coupling loose causing Dishwasher to drain all over the floor.
I'll ___________ repair due to shut off of water - explanation on NRC Invoice.
8. What were weather conditions like? Not ap.
9. Give name and address of any witnesses: Total Plumbing - Keith Nielands Ref. - Rick, Theresa Hayes, Mike Henrick
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.)
Yes, Dishwasher coupling, high pressure safety switch was blown.
13. What other damages do you claim, if any?
None
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?
$58.45, 71.02, total $129.47
16. Why do you claim the City of Dubuque is responsible?
Yes, had not problem prior to this water interruptins. Said this would cost nothing but I was without
I and couldn't drain dishwasher with out running all over the floor.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
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 28th day of Janaury, , 2002.
/s/ Jorja Moore
(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 ~
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: ---~'---"~ ~. ~ ~ !S ~ P-.~> ~ ~ ~/- ~
2. Address: ~ ?~ '-~~
3. Telephone Number: ~_ c:~ ,~/-~-'~- ~,~-~/7~
4. Date of Incident:
5.
Time
of
Incident:
6. Location of Incident (Be specific):
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE.
full details upon which you base your claim. If a City employee
employee's name.) . -~**'~d*,~ ~ ~.~/?
/j ' "--'
(Give
was involved, give the
p ~JU
8. What were weather conVditions like? ~_
9. Give name and address of any witnesses:
10. Did police~inyestigate? (If so, give names of officers.)
\ 1o
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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.)
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible? ~ ~ ~L~
(If yes, give name and address.)
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 f/~2~ day of
(Rev. 1/00 & 7/01)
Residential · Commercial · Industrial
BILL TO
[890 iOVCA
i DUBUQUE, *dk 52001
P;O_ NO. - TERMS
PRO~ECT
COUPLinG
QTY
1
Don Jacqu not
, 5 Main street Dubuque, IA52001
(563.)'556-2394 FAX i563)583-7067
I INVOICE
DATE
1/4/2002 t 11612
2 64 I
bz ~ 0
(NRC) Nieland Refrigeration
P.O.Box 3010
Dubuque, IA 52004-3010
Invoice
DATE INVOICE #
10/30/2001 15382
BI~.L TO
Joda's
890 Iowa St
Dubuque, IA 52001
QUANTITY
DESCRIPTION
P.O. NO, PROJECT
TERMS
!0%10DayNeG0
RATE
TRUCK/TRIP CHARGE 10/29/01
INSPECT ICEMACHINE FOR REPAIR
INSPECT ICE MACHINE FOR NO ICE PRODUCTION. FOUND MACBtNE OFF
ON HIGH PRESSURE SAFETY. RESET SAFET~ & INSPECT OPERATION,
FOUND MACHINE OPERATION, OK. INQUIRE ABOUT WATER
INTERRUPTION, FOUND WATER TO BUILDING AND MACHINE WAS SHUT
OFF ON 10/26/01 FOR METER INSTALLATION. WATER INTERRUPTiON
CAUSED MACHINEtTO SHUT OFF ON HIGH PRESSURE SAFETY.
MAKE: IMI CORNELIUS
MODEL: IWC 330
SERIAL# 6319824BC123
o
A Late penalty charge of 1.5 ~ will be charged on accounts over 30 days. ( $ 5.00
minimum rebilling charge.)
12.00
55.00
0.00
6.00%
AMOUNT
12.00T
55.00T
YOU MAy DEDUCT $7.10 IF PD. BY 11/07/01 THANKS
Total $71.02
0.00T
4.02