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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 ownership information; <br />Street address IsuiHJh Lh<S~ /V<«,'A/gT-gtA.'/C/}- - <br />Legal property description ___ <br />PiD# 3^ -m-J-i ai ooo* <br />1 X ^ ^ ^ '*1 ---------------—--------- ■-------------------------------------- r <br />Listed property owner(s) oP- MJ <br />8. Names of abutting lakeshore property owners; <br />rNorthAVest) <br />(Name Address) <br />rSouth/East) <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 /sLfVtsjJ) TirtL <br />Name of insurance carrier (T<Pc— /aj T~y—---------- <br />Name of insurance agency ------- <br />Policy No. 3 Effective date of coverage <br />Amount of coverage; Public liability, per person, per occurrence <br /><C ^00(^00Public liability, per occurrence ^------- <br />Pase 2 of 5