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i 5. <br />6. <br />7. <br />8. <br />9. <br />Principal purpose of joint use dock is (check applicable items): <br />____ provide boat mooring and lake access for residential propert>'. <br />____ provide swimming access, beach, or offshore dock. <br />^ provide a club or association gathering place for activities. <br />Dock is located on (check applicable item): <br />____one member's private property. <br />____easement or outlot o^^Tled in common. <br />____property leased by the group/association. <br />y property owned by the •^rou-''rssociation. <br />List Dock location and. ownership information: <br />Street address Ars V-/? c^l Sl*Xso4.^0--------------------------- 7 / <br />Legal property description A-irActf-t.o A___________________ <br />PID# __________________________________________________ <br />I Uted nronertv ownerfs'l S/A' x jUX jc ._____________________________ <br />R a. Sox / /t7AJ / <br />Names of abutting lakeshore property owners: <br />rNorth/WesO iE/Ztcicscf^ <br />(Name + Address) <br />fSouth/East'i A->/A___________________________________ <br />(Name + Address) <br />Names of other affected property owners: <br />a>/a _____ <br />(Name + Address) (attach sheet if necessar>’) <br />Insurance Coverage - The jointly used dock is insured by one of the following: <br />____ property owner's homeownc's policy. <br />separate group/association owned policy. <br />List the follow ing information: <br />Name of insured »_________________ <br />Name of insurance carrier -5^ "Pav L- <br />Name of insurance agency CACSo^ — »---------------- <br />Policy No. -/yj Af Effective date of coverage O <br />Amount of coverage: Public liability, per person, per occurrence $ / <br />Public liability, per occurrence $ ^ <br />Page 2 of 5