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* • <br />5. <br />6. <br />7. <br />8. <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 />group/association. HthAJS'Sc'TA' <br />List Dock location and ownership information: <br />Street address <br />‘ .....................— / <br />Legal property description (Sf>ur. ^ ^ Se^c.. 23, / // 7 ^ R <br />PID#______________________________ ^ -7- , <br />Listed property owner(s) ftt-u ^ ^ <br />Names of abutting lakeshore property owners: <br />'North/West' <br />(Name + Address) <br />'SouthyEast <br />(Name + Address) <br />Names of other affected property owners:J <br />(Name + Address) (attach sheet if necessary) <br />Insurance Coverage - The jointly 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 I si -Ak^ -------------— <br />Name of insurance carrier /hlSTUCAf^ . <br />PniiryNn iSm Effective date of coverage <br />Amount of coverage: Public liability, per person, per occurrence <br />Public liability, per occurrence <br />Page 2 of 5