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6. <br />7. <br />8. <br />9. <br />10. <br />Dock is located on (check applicable item): <br />___one member's private propert>'. __ <br />___easement or outlot owned in common. property owned by the group/association, <br />property leased by the group/association. <br />List Dock location and ownership information: <br />Street address <br />Legal property description <br />PID# <br />Listed property owTier(s) <br />Names/addresses of abutting lakeshqre property owners: <br />4 OHimofNorthAVesO <br />(South/Easti /Wfl (il <br />Names/addresses of other affected wop^' <br />________Ammd- <br />owners (attach sheet if necessary): <br />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 ( . S'TolLLltz. <br />Name of insurance carrier _________^ , <br />Name of insurance agency fA;j Ct)A/rcy ____________ ^ <br />Policy No. ^ 5^- I Effective date of average / ^ <br />Amount of coverage: Public liability, per person, per occurrence $_/ <br />Public liability, per occurrence $~/ <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 />____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: _________ ft. and <br />ft. <br />ft. <br />Page 2 of 4