Laserfiche WebLink
r.. <br />1 <br />Principsl purpose of joint use dock is (check applicable items). <br />A provide boat mooring and lake access for residential propert>'. <br />provide swimming access, beach, or offshore dock, <br />provide a club or association gathering place for activities. <br />6.Dock is located on (check applicable item): <br />K 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 />7.List Dock location and ownership information: ^ <br />3lSS~ kL/CTH Zkw.Street address ______ <br />Legal property description_______________ <br />piD# e<? ~/f» -33 - 3b • <br />Listed property owner(s) <br />8.Names of abuttinjg lakeshore property owners: jv . <br />(Name + Address) _ <br />. A4 w7X- <br />(Name + Address) <br />Names of other affected property owners: <br />gt)^3>8f <br />_ fName + Address) (attach sheet if necessmy) <br />9. <br />^ame + Address) (attach sneet it nece^ry; ^ <br />IniuraSS? ^oveS^^Th^jiS^iS^ d<it®if inaredb'y one of the following: <br />property owner’s homeowner’s policy, <br />separate group/association owned policy. <br />^ ^ mList the following information: <br />Name of insured_____V s!D a »J v >A vi <br />Name of insurance carrier <br />Name of insurance agency <br />Policy No.Policy No. __________________Effective date of coverage -------------------- <br />Amount of coverage: Public liability, per person, per occurrence $— <br />Public liability, per occurrence $_3©£t_£®^ <br />Page 2 of 5 <br />iffk I. *