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7. <br />8. <br />9. <br />1 <br />List Dock location and ownership information: . <br />Street address ^^0 /l/. <br />Legal property description/^) ^ j \J’> i "JcJf ^ CJ <br />PID# _Oii -I//W \? \i .MIffListed property owner(s) ^/T'^ <br />Names/addresses of abutting lakeshore property owners: . <br />tNorth/Westt ~Tl) /Y\ I'U ^ H ^l(i}0 A!l H //A <br />(Snulh/F».<0 l'y\LifC>r <br />Names/addresses of other affected property owners (attach sheet if necessary): <br />_______,^0 c. ^_____________________ <br />insurance Coverage • The jointly used dock is insured by one of the following: <br />__ property owner's homeowner's policy. V.^^arate group/association owned policy. <br />Name of insured l/i i "4c)( i(^ \ j . <br />Name of insurance carrier nj^ef \t }ii‘} \' -ff Q S '<f C'\^(0 <br />Name of insurance agency |<(rf/} <L<i ^^yT~'__________ <br />Policy No. - ^ (lO'J riff Bfrective date of co\i^rag^ <br />Amount of coverageT Public liability, per person, per occurrence $ ' <br />Public liability, per occurrence $ ]" <br />'/ J <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: ft. Length of main dock from shore: ft. <br />• • - « r✓ /\ A A IDock setbacks from side property lines at shore: VC L ft. and (J ( <br />12.Dock Construction (check applicable items): <br />____seasonal dock (relocated or replaced each year) <br />____permanent piling with seasonal deck V-.^ pennanent piling and decking <br />____wooden decking _____metal decking <br />Page 2 of 4