Laserfiche WebLink
5. <br />6. <br />7. <br />8. <br />9. <br />Principal purpose of joint use dock is (check applicable items): <br />V provide boat mooring and lake access for residential properry. <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 />____ propeny owned by the group/association. <br />List Dock location and ownership information: <br />Street address S3^C} <br />Legal property description __ <br />PID# __________ <br />i (' <br />Listed propert}’ owner(s) <br />______ O \J', I k)f,4 <br />A,/A — <br />Names of abutting lakeshore propeny owners: , ^ ^ /vi J <br />tNonh/Westi To —W fV/O—iQf • f \J <br />(Name + Address) tl a r /v J <br />tSouth/Fast) --------1(/> <br />(Name -i- Address) A ^ ^ <br />Names of oUser affeaed propeny owners: // ^ 0 <br />MefAcW /\J ^/. <br />(Narhe 4- Address) (attach sheet if necessary) <br />Insurance Coverage - The jointly used dock is insured by one of the following; <br />propeny owner’s homeowner’s policy, <br />separate group.'association owned policy. <br />List the following information: <br />Name of insured I At ( id <br />Name of insurance carrier <br />Name of insurance agency <br />risj<7C. <br />,//«<( fTi.ni.fh Tyj.wJ/a^HmP,'li,-vNn Effective date of coverage $' ' / S <br />Amount of coverage: Public liability, per person, per occurrence S ,Sl36j./j^£- <br />Public liability, pet occurrence S__.5 <br />Page 2 of 5