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5. <br />7. <br />9. <br />Principal 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 />X 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 comnion. <br />property leased by the group/association. <br />property owned by the group/association. <br />List Dock location and ownership information: <br />Street address ^OUwwl dUUltJJ f ^ ^ . <br />Legal property description Zav.i) —Z/iAcT----- <br />P 1 D # - //7 - ^---------------------r i u ^ ^ ^ v-^-------—-------------------------------- . <br />Listed property owner(s) To^_ /<A —— <br />Names of abutting lakeshore property' owners: <br />';i>o >0«_r — <br />(South/East) <br />(Name + Address) <br />(Name + Address) <br />Names of other affected property owners: <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______------------------------------------------ -Name oi insurcu______——----------------------------- <br />Name of insurance carrier *- *>■ £----- <br />Name of insurance agency f '''T' '/» • ---- <br />Policy No. ^-/LZ r^r Hffeclive date of coverage _ 7^/1 ^roiicy i^u. 9 ^ ^ ^------------- <br />Amount of coverage: Public liability, per person, per occurrence <br />Ihiblic liabUity. per occurrence -------- <br />Page 2 of 5