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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 />X one member's private property. <br />____ easement or outlot 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 \<XO\ <br />Legal property description —L— <br />PID# ____________________________— <br />a.Ai ll. <br />Listed property owner(s) x /i i ^ C i M71 <br />Names of abutting lakeshore property owners: <br />(Name + Address) <br />(Snuth/East^ Pa, <br />(Name + Address) <br />Names of other affected property owners: <br />(Name + Address) (attach sheet if necessary) <br />Insurance Coverage - The jointly used dock is insured by one of the following: <br />____property owmer's homeowner's policy. <br />y separate group/association owmed policy. <br />List the following information: <br />Name of insured *^*^^*^*1----- <br />Name of insurance carrier Sc. — <br />Name of insurance agency * 5 ----------------------—-------- <br />Policy No. GLS' Effective date of coverage <br />Amount of coverage: Public liability, per person, per occurrence $ <br />Public liability, per occurrence <br />'/ ' <br />$ /. 0^0. 0^0 , <br />Page 2 of 5