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. <br />7. <br />8. <br />10. <br />List Dock location and ownership information: <br />Street address /rirUV enctfLiiO^. !A^ S‘T33y <br />Legal property description O qtjlo T cevif_______________ <br />pID# oa • iij- 33 /a <br />Listed property owner(s) S'vfhtS. SikvtA />♦ /UntTA^^ecto^ <br />*tiMaT7ty7hf*n At*nA ScuFFSR <br />Names/addresses of abutting lakeshore property owners: <br />rNorth/West^ NcT _______ <br />rSouth/EasO A Ht>lT. ASULLAkg rrH£tT^ MN 5^4?/ <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 kfLLY C a \t£ AteMfdu/omj AlUCttfTt^N cf" cAcNO <br />Name of insurance carrier 1A£ C.tticihiMA'ft CAMA/htiFT <br />Name of insurance agency t <br />Policy No. _________ Effective date of coverage ________ <br />Amount of coverage: Public liability, per person, per occurrence $ /. eoO <br />Public liability, per occurrence $/.ooo, ooo <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 />11.List Dock Use Area Specifications: <br />Width of shoreline: 3 Sh O ’t' ft. Length of main dock from shore: ^ ^ ft. <br />Dock setbacks from side property lines at shore: UO ft. and ITtiT 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