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a <br />n <br />i ‘ <br />it <br />r <br />7.List Dock location and ownership information: <br />Street address j/l/ /^ftn jQr. <br />Legal property description ^ I \J'iA <br />PiD# ^ y\iAr\r''i(( 'f shl^ <br />Listed prop«1yowner(s) /r\ j ^'7^^ <br />8.Names/addresses of abutting lakeshore property owners: <br />(North/WesO 'Jl'WA ^(q 0 ^' K)iri <br />rSniith/RaKt) ~^^/yi (\'?^ ^ ^^ <br />Names/addresses of other affected property owners (attach sheet if necessary): <br />-------------i>ui ^ihu^d----------------- <br />9. Insurance Coverage - The jointly used dock is insured by one of the following: <br />property owner ’s homeowner ’s policy, y separate group/association owned policy. <br />Name of insured [A r-|^f(=3^^frhL9 jff\yY\o{iuy»^r^ <br />Name of insurance c^er' j Art (u <br />---------------------------------------- •----------------------------------------------------------------- ■ <br />-fiO 'Effective <br />Name of insurance agency <br />Policy No. ^,2^ S!^fl . 'Effective date of ^overa^ <br />Amount of coverage: Public liability, per person <br />Public liability, per occurrence <br />, per occurrence S f /HTT) <br />ence S)^ fjjjyj <br />10. <br />J- <br />Security and policing of the jointly used dock and property is provided by (check ^plicable itenjs): <br />____fencing _____security lighting V property owner's presence <br />"ieTT"contract security service othef-(specify) <br />II. DOCKIi <br />11.List Dock Use Area Specifications: <br />Width of shoreline: f {pOCi ft. Length of main dock from shore: ^ ft. <br />Dock setbacks fiom side property lines at shore: ^60 ft. and XA (1 ft. <br />12.Dock Construction (check applicable 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