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• » <br />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 teased by the group/association, <br />property owned by the group/association. <br />List Dock location and ownership information: <br />Street address 2<rtiX <br />Legal property description Oi/TLdT W* _________ <br />PIP# /g ocS^_____________________________ <br />Ut \A$tL S'ibnA ft. <br />JftHJ/ » icu ^PoA________________________ <br />Names/addresses of abutting lakeshore property owners: <br />(North/WesO ^ 7* /TA/^ Wa7________________________________________ <br />fSouth/EasO A. //a VT} E UA* ^4^*^ WM^ATAf Mh/ <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 jCiSLL'^ <br />Name of insurance carrier THir* 'C /NCtuuti^f __________ <br />Name\qf, insurance agency tiukU! i ' A^SHC.y____________ <br />Policy No. CUP *77/ iL \ S Effective date of coverage ______________ <br />Amount of coverage: Public liability, per person, p>er occurrence $ <br />. , Public liability, per occiOTcnce SI,oAt, OOP <br />Sediirity ind policing of the jointly used dock ^dproperty is provided by (check applicable <br />items): . • . •. . < <br />____ fencing ____security lighting property owner ’s presence <br />contract secunty service other (specify) <br />POCK INFORMATION <br />11. List Dock Use Area Specifications: / c ^ <br />Width of shoreline: QSTO -H ft. Length ofmain dock from shore: ^ ft. <br />Dock setbacks from side property lines at shore: iO____ft. and ft- <br />Page 2 of 4 <br />A