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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 />pfQvide bo3t 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. v <br />> t.-sement or outlot owned in common.A; <br />____ property leased by the group/association. <br />____ propertv ’ owned by the group/association. <br />List Dock location and ownersiiip information: <br />Street address <br />Legal property description Lo'T'—L <br />P I D # <br />JQ n ) X I L <br />J <br />Pn jt^hsiL-------------------------------------- <br />Listed property owner(s) Av. A»r t___^ P ^ T l e <br />Names of abutting lakeshore property owners: <br />rNorth/WesO <br />(Name + Address) <br />^niith/East) <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 foiiowing: <br />property owner ’s homeowner ’s policy. <br />7 <br />\,AUJC <br />Y separate group/association owned policy. <br />List the following information: <br />Name of insurance carrier <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