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7.List Dock location and ownership information: <br />Street address_____SlO ISLttMD <br />Legal property description IftLAMO LOT 4b5 <br />PID# 72-no MQ002,__________________________ <br />Listed property owner(s) MlMKiEToKiKlfl ‘POWgf? S<Q\JlftDf?QM <br />8.Names/addresses of abutting lakeshore property owners: <br />fNorth/West) rlogfil - ijgMhfDa ._____ <br />rSniith/fU«t \ - kIoij^. <br />Namesi’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. X separate group/association owned policy. <br />Name of insured MlhiKlgffllAKA <br />Name of insurance agency iMft._________ <br />Policy No. EflFectived^eotcovCTage <br />Amount of coverage: Public liability, per person, per occurrence S \ <br />Public liability, per occurrence S \ ^ nfin^ Ofln <br />10.Security and policing of the jointly used dock and property is provided by (check applicable itenjs <br />____fencing _____security lifting X property owner's presence <br />____contract security service _____other (specify)_________________________ <br />0: <br />II. DOCK INFORMATION <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 />X 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 />P <br />I <br />4 <br />SI <br />1