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5. <br />6. <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 />one member’s private property, <br />easement or ouilot 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 <br />Legal property description__________________ <br />PI D/^ - S3 ' <br />Listed property owircr(s) <br />Names of abutting lakeshore property owners: <br />(^fNort^West)3/ Kk><TU — <br />(Name + Address) <br />3<fer <br />-----^ (Name + Address) <br />Names of other affected property owners: ^ <br />9. <br />(attach sheet if necessary) <br />Insurance Coverage - The Jointly used dock is insured by one of the following: <br />XT property owner’s homeowner’s policy. <br />separate group/association owned policy. <br />List the following information: <br />Name of insured_____/4»t. <br />Name of insurance carrier <br />Name of insurance agency <br />Policy No. <br />I -t-P <br />rh^‘Z.-n^r sT>t-yt—V <br />Effective date of coverage <br />Amount of coverage: Public liability, per person, per occurrence <br />Public liability, per occurrence <br />Page 2 of 5