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5. <br />6. <br />7. <br />8. <br />9. <br />! <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 />property owned by the group/association. <br />List Dock location and ownership information: <br />Street address ________________________ <br />Legal property description <br />PID<^U ff ________ - ------------------ <br />Listed property ownet(s) -^ecp <br />Names of abutting lakeshore property owners: <br />(Nnrth/WesO dnfco^, ^ <br />(Name f Address) / • <br />(South/Easti <br />(Name + Address) <br />Names of otlier affected property owners: <br />(Name + Address) (attach sheet if necessary) <br />Insurance Coverage - The Jointly used dock is insured by one of the foUowing: <br />0 <br />property owner’s homeowner’s policy, <br />separate group/association owned policy.7 <br />List the following information: <br />Name of insured_____ <br />Name of insurance canier <br />Name of insurance agency <br />Policy No.___________Effective date of coverage <br />Amount of coverage: Public liability, per person, per occurrence $ <br />Public liability, per occurrence <br />Page 2 of 5