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5. <br />\c i <br />6. <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 />—provide a club or association gathering place for activities. <br />Dock is located on (check applicable item): <br />____ one member's private property. <br />_____ casement or outlot owned in common. <br />------- property leased by the group/association. <br />—property owned by the group/association. <br />6rAite»-.’ <br />List Dock location and ownership information: <br />Street address 6J5c a — <br />Legal property description FjlO Uk- / —/oo <br />^*•(1 ^piD#_ 2) doui <br />Listed property owner(s) _ ^tC <br />Foj^ I S u'^Cl <br />Names of abutting lakeshore property owners: <br />(Name + Address) <br />fSouth/Fqst_____ <br />(Name + Address) <br />Names of other affected property owners: <br />(Name + Address) (attach sheet if nece-sary) <br />Insurance Coverage - The jointly used dock is insured by one of the followinc»- <br />____ property owner’s homeowner’s policy. <br />—separate group/association owned policy. <br />List the following information: <br />Name of insured f>iC IS^Avp Caa^p <br />Name of insurance carrier <br />Name of fg^ncy ^^f^RvcA/v/ Au S <br />Policy No.<-" i_ V / " 5 Effective date of coverage __/(- ^7 - <br />Amount of coverage: Public liabdity, per person, per occurrence <br />Public liability, per occurrence <br />Page 2 of 5