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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. <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 • 2<0\ I <br />Legal property description OUTL cT fC^LL^j _________________ <br />PID# 3^/1 - i/y> 33 / A ocS^______________________________ <br />Listed property owner(s) ut ,^hml i/a.^Vw # SHbnd fl. ^ <br />ertowa/ » tkni»A Ku ________________________ <br />Names/addressea of abutting lakeshore property owners: <br />fNorth/Westl ^ ^ /TA/^WA/___________ <br />(South/Easti A. Ittvr, Oi'l £. UAt wAjtArA, mm S'S’U-*il <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 IOSL l ^ C-Al/if <br />Name of insur^ce carrier TTfir e tNCiuut^yt __________ <br />Name of insurance agency /iULLt i A^£UCy ____________ <br />Policy No. CAI^ *>7/ iL 13 Effective date of coverage_____________ <br />Amount of coverage: Public liability, per person, per occurrence $ <br />Public liability, per occurrence $ 1,0 At, 6CO <br />Security and policing of the jointly used dock and property is provided by (check applicable <br />items): <br />_____ fencing ____ security lighting property owner's presence <br />____ other (specify)_________________________contract secuntv service <br />DOCK INF0RM.4T10N <br />11. List Dock Use Area Specifications: ^ <br />Width of shoreline: 0.^0 -f- ft. Length of main dock from shore: 4»0 , ft. <br />-•______. _t _______ t Ci.____I C,Dock setbacks from side property lines at shore: 4 O____ ft. and t^iT ft> <br />Page 2 of 4