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7. <br />8. <br />List Dock location and ownership information: <br />Street address __^5^0 ' \ <br />Legal property description '{'fCO^A <br />PID#^^-3. - I \ 1 ^ ! <br />Listed property owner(s) 0" r i-.r >> Vor\t!,:■/* ,V,;Y —f ••/I, ^ <br />Names/addresses of abutting lakeshore property owners: <br />(NorthAVest)________________________________ <br />ISouth/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 fA* • iv. ; . /r w <br />Name of insurance carrier (.Tia H - ;r ' <br />Name of insurance agency |i\l/ orx.c/ V</l.Lt'ri. .(mc___________ <br />Policy No. OZhOH-:'yS 1 ______ Effective date of coverage •'02. <br />Amount of coverage: Public liability, per person, per occurrence $ <br />Public liability, per occurrence $ <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 INFORMATION <br />List Dock Use Area Specifications; <br />Width of shoreline: _________ft. Length of main dock from shore: _________ft. <br />Dock setbacks from side property lines at shore: _________ ft. and _________ ft. <br />Dock Construction (check applicable items): <br />V 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