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6 <br />Principal purpose of joint use is (check applicable items): <br />____ provide boat moOTing and lake access for resklential property. <br />____ provide swimminf access, beach, or offshore dock. <br />)k provide a club or association gatfaring place for activities. <br />Dock is located on (check applicable item): <br />____ one member’s private property. <br />casement or outlet owned in common. <br />____ property leased by the group/association. <br />JL property owned by the group/association <br />List Dock location arul ownership information: <br />Street address 3 lO XsICldA________________ <br />Legal property description B/^ X^ldlfycl R^CjOi'A <br />PI D# N 00 02j____________________ <br />Listed property’ owtkt{s) flT\tt)f]5l'i'Cn^/^A r'Ot] <br />8. <br />7 <br />Names of abutting lakcshore property owners <br />(North/West)________________________ <br />(Name -f Address) <br />(South/East) <br />(Name -f Address) <br />Names of other affected property owners: <br />9. <br />(Name + Addreo , (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 />X separate group/association owned policy. <br />List the following information: <br />Name of insured f)] / ^ Ofl~Phc0^r (xOi TO <br />GRE Tn^urrik\OP Gre^upName of insurance carrier <br />Name of insurance agency JTt)SULfQif[Q^ ^cjU/SOTS -X/I <br />Policy No. ^300Effective date of coverage j/^O f^3 <br />Amount of coverage: Public liability, per person, per occurrence $ f)CO .OOP <br />Public liability, per occurrence $ SOOfOOQ <br />Page 2 of 5