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I <br />Principal purpose of joint use dock is (check applicable items): <br />provide boat mooring and lake access for residential propeny <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 outlot owned in common. <br />_____ property leased by the group/association. <br />_____ property' owned by the group ssociation. <br />List Dock location ai.d ownership information; <br />Street address ^o/CTTi j <br />Legal property description <br />PID#- 13 - <br />Listed property owner(s) <br />Names of abutting lakeshore property owners; ^ <br />/tlsJoiiliAVe.sti <br />(Name + Address) <br />South-East)3 10^ M>a.TH <br />(Name + Address) <br />Names of other affected property owners _ <br />SAjloviy A/oAJ^3f.0c. <br />(Name + Address) (attach sheet if necessary) <br />Insurance Coverage - The Jointly used dock is insured by one of the following; <br />yK 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. ____________ <br />t;r/f 4 JLaA <br />Effective date of coverage <br />Amount of coverage: Public liability, per person, per occurrence S <br />Public liability, per occurrence $. <br />3<=<ik <br />Page 2 of 5