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8. <br />9. <br />10. <br />f <br />ated on (check applicable item): <br />member's private property, <br />asement or outlot owned in common. <br />_ property leased by the group/association, <br />•^property owned by the group/association. <br />4 Dock location and ownership information: <br />Jtreeladdress /c?5 /S'*- H ,/7?/0 <br />Legal property description /4 <br />PID# <br />Listed property owner(s) <br />fc,'. /jry ^ <br />Names/addresses of abutting lakeshore property owners: <br />forth/Westl <br />(South/Easrt /sf/a <br />property owners (attach sheet if necessary):Names/addresses of other affected <br />n/a <br />Insurance Coverage - The j^inUy used dock is insured by Are of UiTMowmg: <br />_ property otynefs homeowner ’s policy, ^separate group/association owned policy. <br />List the following information: <br />Name of insured 'S/o- <br />Name of insurance agency . T. <br />0 icy 0^ ——^ ______ Effective date of coverage 6 Tta o <br />Amount of coverage: Public liability, per person, per occurrencew X- <br />Public liability, per occurrence S 4 ~ <br />hems”:^ policing of the jointly used dock and property is provided by (check applicable <br />■------ fencing-------security lighting property nwnfr'5 presence <br />------- contract secunty service ^ othWeify) <br />DOCK INFORMATrnv <br />11.u-i Specifications: ATT/^ <br />\Vid^ of shoreline: ________ft. Length ofmain dock from shore: <br />Dock setbacks from side property lines at shore:ft. and <br />ft. <br />ft. <br />Page 2 of 4