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r <br />7.List Dock location and ownership information: <br />Street address LiKlCf> A <br />flC*?Legal property description <br />PID#_________Cj 1 ‘ in'- - (0C}7M <br />I t'Z. hfii'esfAtfuCC <br />Listed property owner(8) t <br />8.Names/addresses of abutting lakeshore property owners: <br />(NorthAVest) f)\^ <br />(South/EasO ^7r7.<r f ( ( <br />9. <br />Names/addresses of other affected property owners (attach sheet if necessary): <br />Insurance Coverage - The jointly used dock is insured by one of the following: <br />__ property owner's homeowner's policy. **^eparate group/association owned policy. <br />Name of insured (!/uA <br />Name of insurance carrier 6ti^d tfUrtuii <br />Name of inst^ce ai^cy poKn._________________________________ <br />Policy No. QJv Effective date of co^age ^ 'l-'XSf-dS -thuj • <br />Amount of coverage: Public liability, per person, per occurrence S /, OW, OlfV <br />Public liability, per occunence $ <br />pohnSotC^ KPA^/a/f) X'NS <br />WlftL <br />10.Security and policing of the jointly used dock and property is provided by (check applicable <br />itc^): <br />fencing V. security lighting SA property owner’s presence <br />contract security service ____other (specify) _______________ <br />11. DOCK INFORMATION <br />11.List Dock Use Area Specifications: <br />Width of shoreline: i?.2.o ft. Ungth of main dock from shore: <br />Dock setbacks from side property lines at shore: l>r> ft. and 3a <br />ft. <br />ft. <br />12.Dock Construction (check applicable items): <br />^ seasonal dock (relocated or replaced each year) <br />------permanent piling with seasonal deck_____permanent piling and decking <br />Vf wooden decking metal decking <br />Page2of4