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6. <br />10. <br />Dock is located on (check applicable item): <br />y one member's private property. <br />easement or outlet owned in common. <br />property leased by the group/association, <br />property owned by the group/association. <br />7. List Dock location and otvmership information: <br />Street address <br />/ ^ <br />Legal property description _____ <br />PID#^ //7> I <br />Listed property owner(s) <br />0 <br />8. Names/addresses of abutting lakeshore property owners: <br />(Yf^r^h/Westl ^ <br />f/EastI <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 />X property owner's homeowner's policy.separate group/association owned policy. <br />List the following information: <br />Name of insured <br />Name of insurance carrier <br />Name of insurance agency n«r> <br />Policy No.Effective aate of coverage <br />Amount of coverage: Public liability, per person, per occurrence $ -r <br />Public liability, per occurrence $ .^to. ct>> r <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: y? ix 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