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City of Everetl Tor[ Claim Form <br />1. Rohde, Jaco6 Edward-Samuel, 12/19/1977 <br />2. 830 Wetmorc Ave, Everett, WA 98201 <br />3. Samr. <br />4. Same <br />5. Cell- 253J09-5490, Wnrk-425317-8622 <br />G. Rohdclrl9'/7CcdaoLcnm <br />7. First incident ocarred on O8/29/7.013 at approximately ;:30 pm, <br />Second Incident occm�red or. 09/OS/2013 at approximately 12:.10 am <br />P. 08/29/2013 a[ approximatcly 5:30pm to 09/OS/2013 at �ipproximatcly 12:30am <br />9. Washineton, Snohomish, [veret�, R30 Wetmore Ave <br />]0. N/� <br />11. N/A <br />12. lacob R Trchia Rohde, R30 Wetmnrr. �ve, Evere[t, WA 98201, Jacob-].53-709-5490, rrenia-zne- <br />779-4104 <br />13. Unsurc <br />14. Drenda Stoneclphcr, City oF [veretl Council Member, 425-308-9849, Toured damap,ed home on <br />Saturday 5�7-73 <br />Shelley Wcycr, NW Nelghborhaod Ch-�r, e�nall�nwevcrett@Pmail.com, I have becn emailing <br />pictures and dlscuss:ng event with her <br />Neal Rohde, i"a[hcr, 2�3317 135'" Ave SF., Kent, WA 9A042, ZOGd90�5536, IJIy father came to our <br />house after first Incidenl tn iielp me clean and he has also helped with making phone calls to <br />insurancc mmpanics and dmn �up crews. <br />Bill Houghton, Pemm Insara�ice, PO Box 778, Seattle, WA 9A111, A7.5-712-7753, 0111 fs our <br />insurance adjustcr. I le toured our home aftcr both incidents. <br />John Kac:ka, Alpine Ucaning & Ilcstoration, 1G20 75'" Strr.cl SW, f:verett, WA 9R203, 42;-3AA- <br />%387, John tourecf basement tu recommend proper procedure fnr clean-up and conslructimi. <br />15. Cause ot flooJing w:u Jue lu back up o( cily sewer sys�em due to excrss waler (rom rainslonn. <br />Cont:�minatcd water came up thruugh toilcl, shnwer and floor dr�iin. Exlent of damage still �a <br />6c dclermined. �pproprialc paper.vork to (ollow wi�h pir.tures and pricing. <br />1G. Incident wu reported to dly wniles dcpartmenL ' <br />77. NJA <br />1N. Dnr.umen[s to Pollow <br />19. Monclary damages slill yel to be dr.lermined. Will foltow up with pmper dnr.urnentalion. <br />Signa�urc... Pleasc scc ;dta�hud Tmt Clalm Form <br />