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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 property, <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 propert>’. <br />____ easement or outlet owned in common. <br />____ property leased by the group/association. <br />property owned by the group/association. <br />List Dock location and ownership information: <br />Street address ______________________ <br />Legal property description <br />PID# ______ <br />Listed property ow'ner(s) <br />Names of abutting lakeshore property ovMiers: <br />rNorth/Wesn t ^ ^ <br />fSouth/EasO <br />^^4^e + Address) <br />(Name + Address) <br />Names of other affected property owners: <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 homeowner's policy. <br />' M <br />separate group/association owned policy. <br />List the following information: <br />Name of insured /fc <br />^ Name of insurance carrier lilCS'f l/^Ofuuf _ <br />Name of insurance agency \,</vSQa l^giyC, h) <br />\ Policy No. Effective date of coverage 7/6.^/9^ " <br />Amount of coverage: Public liability, per person, per occurrence <br />tiPublic liability, per occurrence <br />Page 2 of 5 <br />$ 1600 CtXO <br />1-----7 ------- <br />5^