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6. <br />7. <br />8. <br />n <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 />X. property owned by the group/association. <br />List Dock location and ownership information: <br />Street address 5 lO JT.<, In r\A <br />Legal property description Bi& RfiCn'rA /L/yf '*<r <br />Listed property owner(s) m'mnejnn <br />Names of abutting lakeshore property owners: <br />(North/West) _________ <br />(Name + Address) <br />(South/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 following: <br />____ property owner’s homeowner’s policy. <br />X separate group/association owned policy. <br />List the following information: <br />Name of insured Al / (1f (P/1 ~PoUJf^r SQUadron <br />Name of insurance carrier __GRE In ^UY~r, ir\{i <br />Name of insurance agency JTnp <br />Policy No. ^)GC) Q ^Effective date of coverage 7/.30 .3 <br />Amount of coverage: Publicliability, per person, per occurrence $ f)00^QQC) <br />Public liability, per occurrence $ ,5"^ OOH <br />Page 2 of 5