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7. <br />8 <br />10. <br />1 <br />List Dock location and o\\’nership information: <br />Street address Si^ g <br />Legal property description -^CC Arn^^mg £<M\%rrA_________________ <br />PID# ti/A______________________________________________________ <br />Listed property owner(s) G X a Jc <br />Names/addresses of abutting lakeshore property owners: <br />fNorthAVest> ___________________ <br />eSouth/East'i <br />Names/addresses of other affected property owners (attach sheet if necessar>): <br />H/A________^_______________________ <br />9. Insurance Coverage - The jointly used dock is insured by one of the following: <br />property owner's homeowner's policy, j? separate group/association owned policy. <br />Name of insured Jc«»4(yg^ J2or. <br />Name of insurance carrier <br />Name of insurance agency Ci»g^s*A>~64<c»aA^ Hii/e. <br />Policy No. Effective date of coverage / r» <br />Amount of coverage: Public Iiabilit>\ per person, per occurrence $ ao6^ odo ^ <br />Public liability, per occurrence $ /,09^ctit _________ <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 x* other (specify) <br />Auus ust*A<. <br />II. DOCK INFORMATION <br />11. List Dock Use Area Specifications: <br />Width of shoreline: _________ft. Length of main 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