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r ’ll <br />5. <br />6. <br />8. <br />9. <br />Principal purpose of joint use dock is (check applicable items): <br />X 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 ovvTicd in common. <br />_____ property leased by the group/association. <br />_____ property owned by the group/association. <br />7. List Dock location and ownership information: <br />Street address 500 Tonkawa Road <br />Legal property description Section 5. Township 117. Range 23 <br />?\Dtf___________________________________________________ <br />Listed property owner(s)Dr. Glen D. Nelson & Marilyn C. Nelson <br />Names of abutting lakeshore property owners: <br />fNorth/WestIMr. & Mrs. Edwin C. Gaee. 460 Tonkawa RnaH. l.nng Lake, MN 55356 <br />(Name + Address) <br />fSouth/Fastl Mr. & Mrs. Curtis L. Carlson. 500 Tonlc-ma Rnad. Long Lake, MN 55356 <br />(Name + Address) <br />Names of other affected property owners: <br />None <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 Dr. Glen & Marilyn C. Nelson <br />Name of insurance carrier The American Insurance Company______ <br />Name of insurance agency Harris-Homeyer Co., Edina, MN 55424 <br />Policy No. NZA 131 9205 _____ Effective date of coverage 6/3/96 <br />Amount of coverage: Public liability, Ver person, per occurrence $. <br />Public liability, per occurrence $. <br />Page 2 of 5