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iim I <br />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 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 •S"/ D ^ / -S ^ -------------- <br />Legal property description f 6* I SO A./3 —6-0-H <br />piD# ono^----------------- <br />Listed property owner(s) /W ^ <br />Names of abutting lakeshore property owners: <br />fNorth/WesO_______________________ <br />(Name + Address) <br />('South/Eastl <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 owner's homeowner's policy. <br />separate group/association owned policy. <br />List the following information; <br />Name of insured A/f[y(//(/£-TO^C/Kl^ f OCAJ^H S'C\ {jf^Q(lOAL <br />Name of insurance carrier ^ Ol^ (V/C^C^ ------- <br />Name of insurance agency ^ <br />Policy V3. - 009^ Effective date of coverage '7/ (p <br />Amount of coverage; Public liability, per person, per occurrence $ <br />Public liability, per occurrence $ /1 OPO; COO <br />Page 2 of 5