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Claim Fassbinder, Rick & Jean CLAIM AGAINST THE CITY OF DUBUQUE, IOWA /~j~~L~. 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: 2. Address: ~-t~ i 3. Telephone Number: 4. Date of Incident: ~ 5. Time of Incident: 6. Location of Incident (Be specific): ~'~o. 5.~e~ 4~ ~C /~_ ~.~ 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..) 8. What were weather conditions like? 9. Give name and address of any witnesses: 10. Did police investigate? (If so, give names of officers.) 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.) . . -~ deJ~:,~ ~,,.~ct~; 13l What other damages do you claim, if any?. /'Uo x~,~. 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? ~ ~.~O. // 16. WhY do you claim the City of Dubuque is responsible? 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? D~__e~da{~Dub~u:e, lowathis ~Lf, x dayof t~l'{ , 20o~.~. -< ~ (Signature) (Rev. 1/00 & 7/01) ××xXX nsured: XXXXX {nsured: Rick Famsblndar Home; 273 } Mtn=tel St. Dubuque, IA 52001 Esitmator: Estimator: Michael Ammsi~ong Business: 1845 Vv'ash}ngton Dubuque, IA 52001 Dates: Dute of Loss: 3/20/2002 Date lnsp~d: 3/21/2002 Price List: CURRENT Estimate: FASSBINDER Water Home: (563) 55%9081 Fax: (319) 557-2~07 Business: (319] $5%1488 D~¢ Rmceived: 3/2 t/2002 $0.00 Structural ltergs Itemm FASSBINDER Room: Basement 192.00 SF Walls 224,00 SF Wails & Ceiling 3.56 SY Flooring 64,00 SF ~ Wall 24.0o LF Ceil. ParlOr LxWxH 8'0" x 4'0' X 8'0" 32.00 SF Coiling 32.00 sF Floor 24.00 LF Floor Perimeter 32,00 SF Sho~t Well I, WTR DRY 6.00 EA 2, EQU DEHUMID 3 ~00 DA 3. WTR GRM ~5~.00 SF 4. WTR LIFT 32.00 SF 5, WTR PAD 32,00 SY 6. WTR EXTS 32.00 7. FCC AV 1.00 STRUCTURAL Repine Drying fan (l~r day) - No monitoring 2 x $ days 2~,$0 159,00 6 Detach & Reset Dehumidifier 66,00 198.00 Repiac,~ Apply ~i~tctda, mild~w¢lda, or comblnafioo solution 0,14 4,48 Replace Lift earl~t for drying 0,15 4.$O F Replace Remove w~t carpet pad 0.15 4.80 P Repla©e Water extraction/~om floor 0~2 19.84 F Replae~ Carpet - (nmt~riol and 259.I9 259.19 I STRUCTURAL TOTAL 6~0,11 ROOM TOTAL: Basement 650,11 AREA STRUCTURAL TOTAL 6~0.11 Line Item Totals~ FASSB1NDER 6~0.11 192,00 SF Walls 32.00 SF Floor 64.00 SFbon Wall 32.00 SF Ceiling 3,56 SY Floorin$ 32.00 SF Shoo Wall 224.00 SF Walls & Ceiling 24.00 LF Floor Perimeter 24.00 LF Ceil. Pcrlmcter Rick Fassbtnder Page: 2 MA~--29--2002 10 ~07 P~ SERVICEMAST£R 55?250? P.04 ~,ick Fassbinder Page: 3 O&P 1terns - CARPET m-O&P Items EQUIPMENT ~t EXTRACTION & REMEDIATION Non-O&P Items Subtotal Total Doliar~ 2~9,19 Total ~ )liars 198,00 19~.92 390.92 % 60.13% 0,00% Rick Fassbinder Page: 4 '. ~AR--29--2002 10~07 PM SER¥ICEMASTER 55?250? OI;LDER ACIONOWLt~Uuiv~r" · P.06 SH~ 'FO: Dumq~ IA 0,00o O,ODO 2S9.19 2S9.1g o.~o O~br Tots]: