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5. <br />6. <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 />7. List Dock location and ownership information: <br />Street address <br />Legal property description <br />PID # _______ <br />Listed property o\vTier(s) <br />8. Names of abutting lakeshore property oyners: <br />fNorth/WesO <br />(Name + A^dres^)Rtcf U-< <br />(Name + Address) <br />Names of other affected property owners’rro.t- <br />(Name + Address) (attach sheet if necessar>') <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 7 <br />Name of insurance carrier <br />Name of insurance agency ---------------------------- <br />Policy No._________________ Effective date of coverage f' 'f- ^ <br />Amount of coverage: Public liability, per person, per occurrence $_l_ <br />Public liability, per occurrence $_J <br />44 <br />Page 2 of 5