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Principal purpose of joiitt use dock is (check applicable items): <br />provkie boat OKwring and lake access for residential property. <br />_____ provide swimming »cc$s, beach, or offshore dock. <br />____ provide a club or association gathering place for activities. <br />Dock is located on (check applicable item): <br />one member’s private property, <br />easement or outlet owned in common, <br />property leased by the group/association. <br />____ prcpeit)' owned by the group/association. <br />List Dock location and ownership information: M <br />Street address V _____________ <br />( <br />Legal property description <br />PI D 4f <br />Listed property owncr(s) <br />8.Names of abutting lakeshore <br />(N orth^ West)________mrty owners: <br />^South/East) <br />(Name <br />Uj rA ^<n!7 <br />(Name + Address) <br />Names of other affected property owners: <br />9. <br />(Name + Address) (attach sheet if necessary) <br />Insurance Coverage - The jointly used dock is insured by one of the following: <br />property owner’s homeowner’s policy. <br />____ separate group/association owned policy. <br />List the following information: <br />Name of insured <br />Name of insurance carrier <br />Name of insurance agency <br />Policy No. ^3^ 5Y32"/ Effective date of coverage <br />Amount of coverage: Public liability, per person, per occurrence <br />$ J/kl\rirPublic liability, per occurrence <br />Page 2 of 5