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7.List Dock location and ownership information: <br />Street address_________^ 'LM ^ //<^ hi/" <br />Legal property description Lo\^ |■•ir~2~ ^_____ <br />PID#_____________(d yK l4 nr> '? '\ <br />listed property owner(s)__ <br />4i(^ <br />^ |g*rvTi o_ tH lJa/At3 <br />8,nes/ad^TKses of abutting lakeshore property owners:Names/ad <br />(N <br />ISsul <br />Nam(of other affected property owners (attach sheet if necessary): <br />9. Insurance Coverage • The jointly used dock is insured by one of the following; <br />property owner's homeowner’s policy. sq)arate group/association owned policy. <br />Name of insured <br />Name of insurance carrier <br />Name of insurance agency <br />Policy No.___________Effective date of coverage <br />Amount of coverage: Public liability, per person, per occurrence S. <br />Public liability, per occurrence $. <br />10.Security and policing of the jointly used dock and property is provided by (check iq)plicable itenjs): <br />____fencing x security lighting property owner's presence <br />____contract swurity service _____other (specify)_________________________ <br />II. DOCK INFORMATION <br />11. list Dock Use Area Specifications: <br />Width of shoreline: ft. Loiglhofmain dock firom shore; J/)^j ft. <br />Dock setbacks firrm side property lines at shore: ft. and ft. <br />12. Dod(X)onstruction (check applicable items): <br />seasonal dock (relocated or replaced each year) <br />pomanent piling with seasonal deck _ <br />wooden decking ____metal decking <br />permanent piling and decking <br />Page 2 of 4