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5. <br />6. <br />7. <br />8 <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 />_____ or» member’s private property. <br />^ easement or outlet 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 3^0 l\l. jftr/y\ )0r fpCi\JA(^ <br />Legal property description <br />PI D# ____________ <br />3 Wfv l-(r)C\d <br />Listed property owner(s) J 6>7) |^^^)/)'|] <br />\ 4a Ir4 <br />Names of abutting lakeshore property owners: <br />rNonh/WesO "Tn/n [UnJ\My\ HI t)c ^0 ja <br />(Name + Address) <br />(South/Easo^f^^/n fV) (\ y-pr S(^0 Al OA <br />(Name + Address) <br />Names of other affected property owners:ZToh\S)A. SKO fil, 'g’' <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 />y separate group/association owned policy. <br />List the following information: <br />Name of insured ]f \ (^-is f. A (t/AD AllAJL^ Ax QdC i ilLu\ <br />Name of insuratKe carrier <br />Name of insurance agency <br />Policy No. " ?)\ <br />/A/■ t(g^yy ^5Jfd/rtCi4 <br />V f -02^uectlyc date of coverage ^ "(T <br />Amount of coverage: Public liability, per person, per occurrence $ ^^0, /TCl^ <br />Public liability, per occurrence <br />Page 2 of 5