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• • • • <br />6. <br />7. <br />8. <br />Dock is located on (check applicable item): <br />X one member's private property. <br />easement or outlot 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 500 Tonkawa Road <br />Legal property description NW 1/4 - SW 1/4, Section 5, Township 117. Range 23 <br />PID# _________________________________________________-— <br />Listed property owner(s) Dr. Glen D. and Marilyn C. Nelson <br />Names/addresses of abutting lakeshore property owners: <br />fNorth/West)Mr . & Mrs. Edwin C. Gage. 460 Tonkawa Rd. . Long T.ake. MN—15356 <br />rSouth/East) Mrs. Curtis L. Carlson. 550 Tonkawa Rd.« Long Lake, MN 55356 <br />Names/addresses of other affected property owners (attach sheet if necessary): <br />None <br />9. Insurance Coverage - The jointly used dock is insured by one of the following: <br />property owner's homeowner ’s policy. ___separate group/association owned policy. <br />List the following information: <br />Name of insured nr. m<»n n. anH Martlyn r. NpiRnn <br />Name of insurance carrier The American Insurance Co. <br />Name of insurance agency Harris rfomeyer Co., Edina, MN 55424 <br />Policy No. NZAI319205_________Effective date of coverage 6/31/9A <br />Amount of coverage: Public liability, per person, per occurrence $______ <br />Public liability, per occurrence $_____ <br />10. Security and policing of the jointly used dock and property is provided by (check applicable <br />items): <br />_____ fencing _X__ security lighting Ji__ property owner's presence <br />contract security service other (specify) <br />Note: Dr. Nelson's shoreline is 396'; the combined shoreline^ adding <br />Mrs. Carlson's and Gage's is 1,242'. <br />DOCK INFORMATION <br />11.List Dock Use Area Specifications: <br />Width of shoreline: 296 ft. Length of main dock from shore: <br />ft. andDock setbacks from side property lines at shore: <br />ft. <br />ft. <br />Page 2 of 4