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I <br />i: • <br />If. <br />F • <br />. i <br />1 <br />7.List Dock location and ownership information: <br />Street address hoh/ SS^^/ <br />Legal property description Coz^___________ <br />PID# V/7 -:Z^3 JD. ________________ <br />8. <br />Listed property owner(s) ^ ^y/u/c:* /3‘^y-'/<a^n£>/i^ <br />* y7 <br />Names/addresses of abutting lakeshore property owners: <br />fNorth/Wert) <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 ^lop^ <br />Name of insurance carrier <br />Name of insurance zsisdsn' <br />Policy No. t^fiP 'y‘?J //l"^ ? Effective date of Average ^jL n/^ <br />Amount of coverage: Public liability, per person, per occurrence $ <br />Public liability, per occurrence $ y. <br />10.Security and policing of the jointly used dock and property is provided by (check applicable itenjs <br />____fencing _____security lighting yi property owner's presence <br />____contract security service _____other (specify)_________________________ <br />0: <br />n. DOCK INPORMATION <br />11. <br />12. <br />List Dock Use Area Specifications: <br />Width of shoreline: ^ ft. Length of main dock fi'om shore: ^ ^ ft- <br />Dock setbacks fiiom side property lines at shore: ft. and ft. <br />Doc|^ Construction (check qrplicable items): <br />seasonal dock (relocated or rqilaced each year) <br />permanent piling with seasonal deck ____permanent piling and decking <br />wooden decking ____metal decking <br />Page 2 of 4