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7. <br />8. <br />r.ist Dock location and ownership information: <br />Street address SlD P~)i4 <br />Legal property description Kl/y ft^cnvT^ lT)f- <br />PID# 22-\n-2\ 14QDP7__________________ <br />Listed property owner(s) Pf\A)f. f ^^AX/x d ^t)<r \ <br />Names/addresses of abutting lakeshore property owners: <br />fNonh/West^ <br />fSouth/EasO <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 MiNKkgT<gMUA. Powgg SrpviAQgQKA____________ <br />Name of insurance carrier KiOKTU CigiLD t|k.\cq^lgAKlrJ? m. <br />Name of insurance agency IKIC agQQKLW>tO <br />Policy No. Cp _____ Effective date of coverage T* 30»04 <br />Amount of coverage: Public liability, per person, per occurrence $ 1, OOP i OOP <br />Public liability, per occurrence S ij/w^.rvTp <br />Security and policing of the jointly used dock and property is provided by (check applicable <br />items): <br />____ fencing ____ security lighting property owner ’s presence <br />____ contract security service ____ other (specify)_________________ <br />II. DOCK INFOILMATION <br />11. <br />12. <br />List Dock Use Area Specifications: <br />Width of shoreline; _________ft. Length of main dock from shore: ______ft. <br />________ft. and _______ ft.Dock setbacks from side property lines at shore; <br />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