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A <br />6. <br />8. <br />9. <br />Principal purpose of joint use dock is (check applicable items):iX provide boat mooring and lake access for residential property, provide swimming access, beach, or offshore dock, 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 />property owned by the group/association. <br />.ist Dock location and ownership information: <br />Street address <br />Legal property description <br />PID# __________ <br />Listed property owner(s) <br />Names of abutting lakeshore property owners: <br />tNorth/West) ----------------------------------/yyPAJsJ) ’ A <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 <br />Name of insurance carrier <br />Name of insurance agency <br />Policy No. ___________Effective date of coverage <br />Amount of coserage: public liability, per person, per occurrence S. <br />Public liability, per occurrence $. <br />Pace 2 of 5