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L <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 />X. one member's private property. <br />____easement or outlet 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______^15^ KlaASr>i <br />Legal property description ____________________________________________ <br />PI D# - Oc:>^ t________________________ <br />Listed property ouner(s) <br />Names of abutting lakeshore property owners: <br />3 ■ r a/q«.-7>. S <br />(Name + Address) <br />^^hV-asn i 3/ ^ r 0/Z.Vt. <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 />X 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 CLkIcG <br />Name of insurance agency <br />Policy No.Effective date of coverageroiicy iNo. _________________ ------------------- <br />Amount of coverage: Public liability, per person, per occurrence $ SOOj^O <^ ~t <br />-.............. S SVOfPublic liability, per occurrence <br />Page 2 of 5