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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 />\y easement or outlet owned in common. <br />property leased by the group/association, <br />property owned by the group/association. <br />List Dock location and ownership information: <br />Street address <Z\() f\/ f)rAf<e /YlpJ/lcj <br />PID# <br />on jKf) S <br />-r.^n l^iL. / / 1 —7 <br />rNo^thAVestl^c'^,A [I In nAM !1/ 74r^-\f)r. <br />(South/Eastl ''YO ---------S(jiA.' Pf^€)r. <br />Names/addresses of other affected property owners (attach sheet if necessary): <br />Xpo rTA i <br />Insurance Coverage - The jointly used dock is insured by one of the following: <br />__propern- owner ’s homeowner ’s policy. \^^eparate group/association owned policy. <br />List the following information: <br />Name of insured / | t. y FQ ^^//] 1 f / ^/Ccf)r\ <br />Name of insurance carrier r, ^S r <br />e agen^ A (7^ h\'H./V /J^\ ( L J <br />Policy No.-p^ < / T ? nX -Elfective date oTcovei^ge ^_________ <br />Name of insurance <br />Amount of coverage: Public liability, per person, per occurrence $ j nni) , <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 ___Y- property owner ’s presence <br />contract security service other (specify) <br />DOCK INFORMATION <br />11. <br />Dock setbacks from side property lines at shore: IT (Tl) <br />List Dock Use Area Specificatm^/^ . <br />Width of shoreline: I (p 6^ Length of main dock from shore: 7-^ ^ ft. <br />ft. and <br />Page 2 of 4