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8. <br />9. <br />Principal purpose of joint use dock is (check applicable items): <br />y 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 ouilot owned in common. <br />property leased by the group/associaiion. <br />property owned by the group/association. <br />List Dock location and ownership information: <br />address NiortK <br />Legal property description ?a.fV Lot 1- <br />p I D # _______\n Z2.__OOC^ <br />Listed property owner(s) --------------------------------- <br />Names of abutting lakeshore property owners: <br />tNorth/West) ------- <br />(Name + Address) <br />___________________ <br />(Name + Address) <br />Names of other affected property owners: <br />South/Easf <br />(Name + Address) (attach sheet if necessary) <br />Insurance Coverage - The jointly used dock is insured by one of the following: <br />y( property owner ’s homeowner ’s policy, <br />separate group/association owned policy. <br />List the following information: <br />Name of insured [4 —------------------------- <br />Name of insurance carrier C (VA ______________________— <br />Name of insurance agency <br />Policy No, Cl y\^ Effective date of coverage----- <br />Amount of coverage: Public liability, per person, per occurrence $_ |,D0Oi^ <br />Public liability, per occurrence $—il OOOiOd^ <br />Page 2 of 5