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APPLICATION <br />PRE -QUALIFICATION FOR THE CITY OF SOUTH BEND, INDIANA SEWER <br />INSURANCE PROGRAM <br />Pre -Qualification Category <br />Second Opinion Excavation Special <br />Attach copies of the following documents: <br />1. License Number <br />2. Bond letter stating limits for single project and aggregate program <br />3. (Corp. or LLC Only) Corporate authority and/or proof of registry with the Secretary of State to <br />do business in Indiana <br />Principal Place of <br />autia, �0.Gtl�Ylc� <br />Business: <br />Mailing Address: <br />�me <br />Telephone: <br />Cell: Fax: <br />E-Mail: <br />( ) X I-rl <br />(JXI) bl\$ (br)q) <br />day c`�Rc 10mb <br />Ownership Information <br />(Identify all owners ifthe <br />Conpae}t rfapplicable) <br />(''h^ b / <br />I�-V i cb P• r�CLrrl�, Csv (p <br />Nature of Company's <br />Business <br />(B,"ie11y describe the type of <br />sel,.ices)aiircoiiilatryprovades) <br />M� c po\-�.l�eluSk�io\ <br />Yie�S <br />(Provide references as needed to <br />validate esperienceforspecific <br />pre-9naliftcation) <br />14 <br />S, cam <br />