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7. List Dock location and ownership information: <br />Street address_______________________________________ <br />Legal property description 1~Ck.A~ / f' ^ <br />PID#________________________________________________________ <br />Listed property owner(s)___________________________________________ <br />8 Names/addresses of abutting lakeshore property owners: <br />rNorth^esO CfO* H dl^ <br />tSouth/Eastt______ <br />Names/addresses of other aflected property owTiers (attach sheet if necessary): <br />9. Insurance Coverage • The jointly used dock is insured by one of the following: <br />__property owner ’s homeowtier's policy. V^separate group/association owned policy. <br />Name of insured <br />Name of insurance carrier _ <br />Name of insurance agency <br />Policy No. ____________Effective date of coverage <br />Amount of coverage: Public liability, per person, per occurrence $. <br />Public liability, per occurrence $. <br />10. Security and policing of the jointly used dock and property is provided by (check applicable <br />items): . <br />____ fencing security lighting \y property owner's presence <br />____contract security service _____other (specify)___________________________ <br />II. DOCK INFORMATION <br />11. List Dock Use Area Speci fications: <br />Width of shoreline: '2'7>0 ft. Length of main dock from shore: ft. <br />Dock setbacks from side property lines at shore: ft. and /O 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 />____wooden decking _____metal decking <br />Page 2 of 4