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5. <br />6. <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 />'j/[ easement or outlot oNMied 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 <br />Legal property description <br />PID# ______ <br />AoT:._Li. <br />Listed property owner(s)0^T"y r <br />Names of abutting lakcshore property ovNTiers; <br />rNorth/Wesfi ________________________ <br />(Name + Address) <br />rSouth/Easf) <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___ <br />Name of insurance carrier <br />Name of insurance agency <br />Policy No. _________Effective date of coverage <br />Amount of coverage: Public liability, per person, per occurrence $. <br />Public liability, per occurrence S. <br />Page 2 of 5