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5. <br />6. <br />7. <br />8. <br />9. <br />Principal purpose of joint use dock is (check applicable items): <br />X provide boat mooring and lake access for residential property. <br />provide swimming access, beach, oi uffjhorc dorlr <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 intormation: ^ ^ <br />Street address <br />Legal property description <br />PID#_____________ <br />Listed property owner(s) _ <br />jjLocl^'3 <br />Names o'' abutting lakeshore prope^ owners: ^ <br />(Name + Address) . <br />(M/trih/Westl <br />^®th/Eastl A jU hi=>tr^ej) <br />(Name + Address) <br />Names of other affected property owners: <br />(N^r+ Address) (attach sheet if necessary) <br />Insurance Coverage - The joinUy used dock is insured by one of the following; <br />____ property owner ’s homeowner ’s policy. <br />separate group/association owned policy. <br />List the following information: <br />Name of insured <br />'f' Name of insurance carrier f\d ---------------- <br />^ Name of insurance agency — <br />- - A.,J - /? no <br />/\ roncy iNu. I r / V uf / L/n / / ui--- -------------------- ---------"" 1/^1 <br />^Amount of coverage: Public liability, per person, per occurrence <br />Public liability, per occurrence $ ICTLf'TCM <br />Page 2 of 5