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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. X property owned by the group/association. <br />List Dock location and ownership information: <br />Street address ISot O ^ g 1 i jaiT ORoNo irifJ <br />Legal property description OPT LaT / <br />PID# <br />Listed property owner(s) hj i nuJ hJER S <br />8.Names/addresses of abutting lakeshore property owners; f£L ^ / 3^7 <br />fNorth/Wesn/^7US/r PtYlPry fj-LP IS30 ^i^OfL£LtAJ^______ <br />f South/EasO Y(\\tN /y >' a/ rvi a/ ^ ; 7/S^ LI Ui= <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 />10. <br />List the following information; <br />Name of insured/^TfOAj <br />^'’me of insurance carrier IT Si ITaJS>.. Cn - <br />-i. *e of insurance agency 3 <br />Policy No. ~7 9 Effective date of coverage 3 "hVS <br />Amount of coverage: Public liability, per person, per occurrence $ I ^ (yCO^ « <br />Public liability, per occurrence $ i (rtrA ntr^ ^ <br />Security and policing of the jointly used dock and property is provided by (check applicable <br />items): <br />____fencing X security lighting _____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: <br />Dock setbacks from side property lines at shore: Y.5* ft. and <br />__ft. <br />ft. <br />Page 2 of 4