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7. <br />8. <br />9. <br />10. <br />List Dock location and ownership information: <br />Street address <br />Legal property description ______________________________________ <br />PID#______________________________________________ <br />Listed property owner(s) ^C)Cf4f i~C- AS*^^j C/ATfO/^ <br />Names/addresses of abutting lakeshore property owners: <br />fNorthAV esi)___________________________________ <br />fSoutli/East) I <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 />xV^roperty owner's homeowner's policy. separate group/association owned policy. <br />Name of insured /A *7/0aJ <br />Name of insurance carrier Hfurts <br />Name of in^ance agency <br />Policy No. m L 5S 0 tX Effective date of Average Slllat <br />Amount of coverage: Public liability, per person, per occurrence $__JLfiEDL, <br />Public liability, per occurrence $ int <br />L} <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 />11. DOCK INFORMATION <br />11. 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 />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 />X wooden decking metal decking <br />Page 2 of 4 <br />__