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7.List Dock location and ownership information: <br />SlteetaddfM. /7/V 'T^etj * IS At AW 7^jg i«nt. <br />Legal property description____________________________________________ <br />PID# _____ _____________________ <br />Listed property owner(s)h/ll f ^5 5 o<£y “HcVt7 <br />8.Names/addresses of abutting lakeshore property owners: <br />fNofdi/WestI_________________________________ <br />iSoudi/Eastl <br />Names/addresses 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. separate group/association owned policy. <br />Name of insured 4./// <br />Name of insurance carrier • <br />Name of insurance agency Shji-a <br />Policy No. QL 2. Effective date of coverage ^ 3 Jf/o i <br />Amount of coverage: Public liability, per person, per occurrence $ /, DQOt i>oo <br />Public liability, per occurrence $ /j t»oo^ ooo <br />10.Security and policing of the jointly used dock and property is provided by (check applicable iterrjs): <br />____fencing _____security lifting _____property owner's presence <br />contract security service other (specify) <br />II. DOCK INFORMATION <br />11. List Dock Use Area Specifications: <br />Width of shoreline: X^3.^ Ufi. Length of main dock fiom shore: //2- <br />Dock setbacks fiom side property lines at shore: ^0 ft. and <br />ft. <br />ft. <br />12. Dock Construction (check applicable items): <br />X seasoiud dock (relocated or replaced each year) <br />____permanent piling with seasonal deck _____permanent piling and decking <br />^ wooden decking metal decking <br />Page 2 of4