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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 />____ one member’s private property. <br />easement or outlot owned in common. <br />____ property leased by the group/association. <br />X property owned by the group/association. <br />List Dock location and ownership information: <br />Street address ^ ID Gt__ <br />Legal property description F)l (b T ^ i* <br />pID# <br />u>i <br />Lbted property owner(s) /Tl TO^J -----'POLU <br />Names of abutting lakeshore property owners: <br />(Nnrth/WesO <br />(Name + Address) <br />fSnuth/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 />X separate group/association owned policy. <br />List the following information:; following information: ^ <br />Nameofimured T/l/miP-fp nfr <br />Name of insurance carrier P.— <br />‘ Tl/Name of insurance agency Aci(jlS(?r$, . <br />Policy No. % ^ '5COfi^2. Effective date of coverage . <br />Amount of coverage: Public liability, per person, per occurrence $_^QO,OQO. <br />Public liability, per occurrence $_^0QjMQQ <br />Page 2 of 5