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7. <br />8. <br />9. <br />Principal purpose of joint use dock is (check applicable items): <br />____ provide boat moormg and lake access for residential property. <br />provide swimming access, beach, or offshore dock. <br />tx^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: < , -w <br />S««t address O <br />Legal propert>- description ------- <br />PID# ^ V 2.2-//7-23 <br />Listed property owner(s) <br />J>8 <br />Names of abutting lakeshore property owners: <br />rNorth/West) <br />(Name + Address) <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 foUowing: <br />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 U^^S T^/^aJ LOo /2i-^ <br />Name of insurance agency <br />Policy No. c7/27<3 Effective date of coverage <br />Amount of coverage: Public liability, per person, per occurrence $ J Pg/ <br />Public liability, per occurrence <br />Page 2 of 5 i