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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.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 Zo 7^ ,3/v <br />Legal property description ^/t >4_________________ <br />PID# _____________________________________________________ <br />Listed property owner(s) ^/<P- <br />P.p.QaX SS5SI <br />Names/addresses of abutting lakeshore property owners: <br />rNorth/WesO ^ __________ <br />fSouth/EasO AJ /Ar <br />Names/addresses of other affected property owners (attach sheet if necessary): <br />ajM__________________________ <br />9. Insurance Coverage - The jointly used dock is insured by one of the following: <br />property owner's homeowner's policy. K separate group/association owned policy. <br />List the following information: <br />Name of insured jSVtf- <br />Name of insurance carrier A h /<- ^g <br />Name of insurance agency ♦ <br />:ive date ofcov <br />\ <br />Policy No. Effective date ofco^rage 6cJ2.<9/fir-‘6^ZSi/t^ <br />Amount of coverage: Public liability, per person, per occurrence $ y^d<ao.aaO <br />Public liability, per occurrence $ /.Ac^.ooci <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 >e- other fSDecifvl/a;ig^<5gi6f ALP'S <br />VfiUAc. <br />»CK INFORMATION <br />11.List Dock Use Area Specifications: .5€<. <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