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APPLICATION <br />PRE -QUALIFICATION FOR THE CITY OF SOUTH BEND, INDIANA SEWER <br />INSURANCE PROGRAM <br />Name of <br />Dll* <br />Pre-Qualifi cation Category <br />Second opinion <br />Attach copies of the following do <br />1. License NUmber <br />Excavatioll <br />[?"f <br />LLc.,. <br />Z. L'ond letter stating limits for single project and aggre gate p ro gram <br />3. (Corp. or LLC Only) Corporate authority and/or proof of registry with the <br />do business in Indiana <br />Principal Place of <br />Business: <br />Mailing Address: <br />Telephone. <br />2 p_ Mn <br />Ownership Infoi-mation <br />tlelenl& all owners �flhe <br />Nature of Company's <br />Business <br />(Brie <br />fly describe the tipe q1' <br />seili ce,vl'o if j' (' ili air i' pi- 1,,i .v) <br />(Provide rO�rences as needed to <br />re-q ua l� Pleat n) <br />Cell: <br />(6'7y) 2%gb- 0713 <br />MtON^ <br />Ltic cft.,s <br />is s �, <br />Fax <br />fie � e r4pwe ? S 0 us + G erk. <br />%19-a s a^ C 0 on^ J"4r <br />14 <br />Special <br />C1 <br />Secretary of State to <br />I il: <br />00, <br />/010,g 01 eeo. <br />IVA <br />S"7y- 5"/ Y.- 6'9 2 o <br />P <br />C. "a 14 +w► I GorA <br />