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? *•7. <br />8. <br />9. <br />10. <br />IL <br />List Dock location and ownership information: <br />Street address RA,______ <br />Legal property description <br />PID# <br />Listed property ownerCs)^ <br />/Q^ >7/ih *JoA/fSO/\r <br />Names/addresses of abutting lakeshore property owners: <br />fNorth/Westt 7T^ <br />2SPO ^ei <br />Names/addieases of other affected property owners (attach sheet if necessary): <br />Insurance Coverage - The jointly used dock is insured by one of the following: <br />^Cpropertv owner's homeowner's policy.__separate group/association owned policy. <br />Name of insured <br />Name of iiuurance carrier <br />Name of insurance agency <br />Policy No.____________Effective date of coverage <br />Amoimt of coverage: Public liability, per person^ per occurrence $. <br />Public liability, per occurrence $ <br />contract security service <br />Security and policing of the jointly used dock an^roperty is provided by (check ^plicable itefijs <br />____fencing security lighting V^propertv owner's presence <br />security service otheffs^iiother (specify) <br />0: <br />CK INFORMATION <br />11. List Dock Use Area Specifications: ~ <br />Width of riwreline: ft Length ofmain dock from shore: ft <br />Dock setbacks from side property lines at shore:________ft. and _________ft. <br />12. Dock Construction (check ^licable items): <br />____seasonal dock (relocated or replaced eac! <br />____permanent piling with seasonal deck <br />____wooden decking _____metal deckin <br />permanent piling and decking <br />Page 2 of 4