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5. <br />6. <br />7. <br />8. <br />9. <br />Principal purpose of joint use dock is (check applicable items): <br />_ provide boat mooring and lake access for residtntial propertv’. <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 />ji mft member^g private property. <br />easement or outlot owned in common. <br />____ property leased by the group/association. <br />property owned by the group/associ ,:ion. <br />List Dock location and ownership information: <br />Street address S>\N6re Drtvie_________________^_________ <br />€»vV.6■t2/5ec^JTftwi^sK\pu7/ Rvr>3e 23- <br />I^gal property description <br />p I D # 000<^__________________________—------------------— <br />Listed property owner(s) U,^\ch4ri. Xue.k»v\u\------------------------------- <br />Names of abutting lakeshorc properry owners: <br />rtv;nr.h/Wns.t Robee^- ___Meog PJorVK Dr.v« <br />fSouth/East) <br />(Name + Address) <br />PxviA 6>ss <br />(Name + Address) <br />Names of other affected property owners: <br />tName + Address) (attach sheet if necessary) <br />Insurance Coverage - The jointly used lock 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. _ Effective date of coverage ------ <br />..\mount of coverage: Public liability, per person, per occurrence <br />Public liability, per occurrence $ Z, CO^ 00^ <br />Pace 2 of 5