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m • • •» .• <br />7. <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 />property owned by the group/association <br />List Dock location and ownership information. ^ <br />Street address <br />Legal property description <br />PID# ____________ <br />Listed property owner(s) <br />8. Names of abutting lakeshore property o^er^ <br />(North/West) <br />(Name + Acdressj <br />r.<?oiith/Easri ^ <br />r <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 V ~ \( <br />Name of insurance carrier <br />CMName of insurance agency ^C . --------------------- <br />Policy No.______________ Effective d^ of coverage / jnr” —' M /ifl ^ <br />Amount of coverage: Public liability, per person, per occurrence $—L <br />Public liability, per occurrence $__1 <br />Page 2 of 5