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7. <br />Principal purpose of joint use dock is (check applicable items): <br />provide boat mooring and lake access for residential property. <br />'X provide swimming access, beach, of effefa ore 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 />property owned by the group/association. <br />List Dock location and ownership information: <br />Street address ^Cl ______ <br />Legal property description CC. <br />P I D #______________________________________________ <br />Listed property owner(s) _____________________________ <br />8 <br />9. <br />Names of abutting lakeshore property owners: <br />(^faHh/West) l/cLL\VPli' ^2-^\ ^ t:i) r <br />(N^e + Address) <br />(Sflfllh/Hast) ^____H 2. ^ Dl^ <br />(Name + Address) <br />Names of other affected property owners: <br />« <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 lollowing information: <br />Name of insured <^cjU/O q trs • <br />Name of insuraiKe carrier ________________ <br />Name of insurance agency , <br />Policy No. Qpf\/ ^Effective date of coverage '^'^9-93^ <br />Amount of coverage: Publicliability, per person, per occurrence $ A/TTH)^ <br />Public liability, per occurrence <br />Page 2 of 5