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6. <br />7. <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. 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 />8.Names/addresses of abutting lakeshore property owners: ^ <br />(NorthAVesO HLfC.di^ <br />fSouth/Easrt KpKJ 2-JT / «-<'< V <br />Names/addresses of other affected property owners (attach sheet if necessary): <br />9. <br />10. <br />Insurance Coverage - The jointly used dock is insured by one of the following: <br />__property owner ’s homeowner's policy. 3<!^parate group/association owned policy. <br />List the following information: <br />Name of insured foCfsT Cnnn-iru ______________ <br />Name of insurance carrier UJfST /Jlu^iia f <br />itxu) .Name of insurance diSfinoy ^Ooke.^Ansnn _____ <br />Policy No. dPti ^7-^ <br />Amount of coverage: Public liability, per person, per occurrence $ ^ OOP <br />Public liability, per occurrence $ i^dO^d/iO <br />Security and policing of the jointly used dock and property is provided by (check applicable <br />item^ . <br />X fencing security lighting K property owner ’s presence <br />____contract security service _____other (specify)_________________________ <br />DOCK INFORMATION <br />11 . List Dock Use Area Specifications: <br />Width of shoreline: ft. Length of main dock from shore: ^ 6? ft. <br />Dock setbacks from side property lines at shore: 3 ft. and 3/9 ft. <br />Page 2 of 4