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6. <br />7. <br />8. <br />9. <br />10. <br />Dock is located on (check applicable item): <br />___one member’s private property. <br />___easement or outlot owned in common. <br />property leased by the group/association. <br />property owned by the ^up/associ____ation. <br />List Dock location and ownership information: fy jr^hfe <br />Street address ________ <br />Legal property description Jhh-hr' <br />PIP# <br />Listed property owner(s) Jj <br />Names/addresses of abutting lakeshore property owners: <br />fNorthAVesrt ___________ <br />fSouth/Eastl <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 />__property owner's homeowner's policy, r^^eparate group/association owned policy. <br />List the following information: <br />Name of insured Tj^*^ <br />Name of insurance carried <br />Name of insurance agency <br />Policy No. cf^tEffective date of coverage <br />Amount of coverage: Public liability, per person, per occurrence $ <br />Public liability, per occurrence <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 K other (specify) ca/x^no^______ <br />DOCK INFORMATION <br />11.List Dock Use Area Specifications: <br />Width of shoreline: SQOQ’* ft. Length of main dock from shore: 70 _____ft. <br />Dock setbacks from side property lines at shore: SVO ft. and __ft. <br />Page 2 of 4 <br />11 <br />ir-A? ■ FT ,v—. i. t •.*