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7. <br />8. <br />10. <br />List Dock location and ownership information: <br />Street address -Tsi-ZiVO <br />Legal property description »• i-cT <br />PID# 7X0 - luCt'.t'X_______________________ <br />\ <br />Listed property owner(s) pgu.>f:y» <br />Names/addresses of abutting lakeshore property owners: <br />fNorth/WesO _______________________________ <br />fSouth/Eairt^_______________________________ <br />Names/addresscs of other affected prttperty i<»-ncrs (afach sheet if necessary): <br />9. Insuranire Coverage - The jointly used dock is insured by one of the following: <br />property owTier's homeowner's policy. y~~ separate group/association owned policy. <br />Name of insured /VI ^^eXtfe K nik^L^ <br />Name of insurance carrier ^Qer /ip/y>p______ <br />Name of insurance agency ^Za J^iQA aa ^ nfiyn^,0< ^ X a <^ <br />Policy 'Ho Cff/lPt4^C:^ ______ Effective date of coverage ___ <br />Amount of coverage: Public liability, per person, per occurrence $ <br />Public liability, per occurrence $ iftDCb'ftSSO <br />Security and policing of the jointly used dock and property is provided by (check applicable <br />items): <br />____fencing _____security lighting "~A property owner's presence <br />____contract security service _____other (specify)__________________________ <br />II. DOCK INFORMATION <br />11 . List Dock Use Area Specifications: iP» Rn»ch£O <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 />^ 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 <br />J