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I <br />L <br />6. <br />7. <br />8. <br />10. <br />Dock is located on (check applicable item): <br />___one member’s private property.property leased by the group/association. <br />easement or outlot owned in common. property owned by the group/association. <br />List Dock location and ownership information: <br />Street address <br />Legal property description ^ <br />PID# - // 7 ’ ^ 3 / ^ <br />Listed property owner(s) ^ <br />Names/addresses of abutting lakeshore property owners: <br />fNorth/WesO _______________________________ <br />(South/Eastl <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 />propert>' owner's homeowner's policy. ^ separate group/association owned policy, <br />List the following information: <br />Name of insured ^f ^ C'^ ^ ^ ^ <br />Name of insmance carrier ----------- <br />Name of insurance agency <l'£> >»t^-f ^- <br />Policy No. n y V; ^ - ^^ffective date of coverage 7~ <br />Amount of coverage: Public liability, per person, per occurrence S <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 V property owner s presence <br />____ contract security service ____other (specify)_________________________ <br />DOCK INFORMATION <br />11. List Dock Use Area Specifications: ^^6 <br />Width of shoreline: ________.ft. Length of main dock from shore: _________ft. <br />ft.Dock setbacks from side property lines at shore;ft. and <br />Page 2 of 4