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»1 ■ <br />Pi <br />. i <br />■- * <br />■li <br />7.and ownership infomiati <br />ZfcWz-Tt)! <br />~~ (i cr <br />List Dock location and ownershin information: <br />Street address <br />Legal property description Lc> T ^ <br />PID# <br />o^/■/ ^4- ^ <br />Listed property owner(s) <br />8.Names/addresses of abutting lakeshore property owners: <br />tNorth/Wesrt ______________________________ <br />fSouth/EasO <br />Names/addresses of other affected property owners (attach sheet if necessary): <br />9. hisurance Coverage • The jointly used dock is insured by one of the following: <br />property owner's homeowner's policy. separate group/association owned policy. <br />Name of insured <br />Name of insurance carrier ^ <br />Name of insurance agencjT^^TXIi^S^ <br />Policy No._________________Effecti^ date of coverage <br />S6'‘‘Amount of coverage: Public liability, per person, per occurrence $ <br />Public liability, per occurrence <br />I-njT <br />$ / * (J, <br />10. <br />contract security service <br />Security and policing of the jointly used dockapd property is provided by (check applicable iten(s): <br />____fencing _____security lighting property owner's presence <br />h^Csioth^ (specify) <br />n. DOCK INFORMATION W- <br />11. List Dock Use Area Specifications: <br />Width of shoreline:________ft. Length ofmain dock from shore: <br />Dock setbacks from side property lines at shore:________ft. and <br />ft. <br />ft. <br />12. Dock Construction (check applicable items): <br />____seasonal dock (relocated or replaced each year) <br />____permanent piling with seasonal deck _____permanent piling and decking <br />wooden decking ____metal decking <br />Page 2 of 4 <br />■ :=’»