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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. 'pC property owned by the group/association. <br />List Dock location and ownership information: <br />Street address <br />Legal property description <br />PID# <br />Listed property owner(s) <br />Names/addresses of abutting lakeshore property owners: <br />fNorthAVesO _________________ <br />(South/East) <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 />property owner's homeowner's policy. separate group/association owned policy. <br />List the following information: <br />Name of insured // C'y' <br />Name of insurance carrier <br />Name of insurance agency /■wyrtA/f2’Cy-4^ <br />Policy No. Effective date of coverage <br />Amount of coverage: Public liability, per person, per occurrence <br />Public liability, per occur ^nhe %/. c7S>C> <br />Security and policing of the jointly usedjddck and property is provided by (check applicable <br />items): ^ <br />____ fencing seci^ity lighting X propert>- owner ’s presence <br />dritvcontract security service <br />X Other (specify) <br />norK INFORMATION <br />1 1 . List Dock Use Area Specifications: <br />Width of shoreline: £ ^ ? ft. Length of main dock from shore: / ft. <br />Dock setbacks from side property’ lines at shore:ft. and ft. <br />Page 2 of 4