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D. <br />6. <br />7. <br />8. <br />9. <br />Principsl 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 outlot owned in common. <br />____ property leased by the group/association. <br />v/ property owned by the group/association. <br />List Dock location and ownership information: <br />Street address _______^^ <br />Legal property description “2. — <br />PID# ________________________________________________________ <br />Listed property owner(s) At>4_ \j\s ^—O p <br />Names of abutting lakeshore property owners: <br />t North/West)________________________ <br />(Name + Address) <br />LSnuth/East) <br />A- <br />(Name + Address) <br />Names of other affected property owners: j <br />tr <br />iName + Address) (attach sheet if necessary) <br />Insurance Coverage - Tne 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____/sL-ArJ >2) Vc T'^XAtJs—------------------------- <br />Name of insurance carrier ----- <br />Name of insurance agency /V^ —/a/s—^— <br />Policy No. CP (S'/91^/______Effective date of coverage <br />Amount of coverage: Public liabUity, per person, per occurrence S 57V?, <br />Public liability, per occurrence S _ <br />Page 2 of 5