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5. <br />6. <br />7. <br />8. <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 ovsTjership information: <br />Street address ^^5 e-X)fU e <br />Legal property description _______ <br />piD# n-ni-z-=i> <br />Listed property owner(s) <br />Names of abutting lakeshore property owners: <br />(Name + Address) <br />rNorth/Westi <br />(South/EasO ________________ <br />(Name + Address) <br />Names of other affected property owners: <br />9. <br />(Name + Address) (attach sheet if necessary) <br />Insurance Coverage - The jointly used dock is insured by one of the following: <br />Y property owner's homeowner's policy. <br />____ separate group/association owned policy. <br />List the following 'nformation: <br />Name of insured ___ <br />Name of insurance carrier CN0 <br />Name of insurance agency _____( e <br />Policy No. Pi Effective date of coverage <br />Amount of coverage: Public liability, per person, per occurrence $ \\^00i0C>0 <br />Public liability, per occurrence $ l| OOOiOOb <br />Page 2 of 5