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5. <br />6. <br />7. <br />Principal purpose of joint use dock is (check applicable it?ms): <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 />property owned by the group/association. <br />List Dock location -nd ownership information: <br />Street address po- ^ <br />Legal property description ________________ <br />P I D # oq -zg /r)c/Aj,c y 22-117-23 ^2, 00/9 <br />Listed property owner(s) .___________ <br />8.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 />9. <br />(Name 4* 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 following information: <br />Name of insured 'Ps J_^c . <br />Name of insurance carrier <br />Name of insurance agency Ta/SArj\/tSoj^_____ <br />Policy No. a/ (^/Z"7d Effective date of coverage <br />Amount of coverage: Public liability, per person, per occurrence $ 5Wj 0^6 <br />Public liability, per occurrence $ cdo <br />Page 2 of 5