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5. <br />6. <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 />provide a club or association gathering place for activities. <br />Dock is located on (check applicable item): <br />^ one member’s private property. <br />___easem 'nt or outlot owned in common. <br />____ property leased by the group/association. <br />___ property owned by the group/association. <br />List Dock location and ownership information: <br />Street address 3)^^ <br />Legal propel ty description_____ <br />P I D # //->.. '2A- as- / <br />Listed property owner(s) <br />8. Names of abutting lakeshore property owners: <br />gj^/Wesfi = <br />^ (Name + Address) <br />/^'tii/East> <br />(Name + Address) <br />Names of other affected property owners: <br />(Name + Address) (attach sheet if necessary) <br />Insurance Coverage - Tbe 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 u------------------------------ <br />Name of insurance carrier ^ ------------------------—---------.V*-- <br />Name of insurance agency (7di\~n<-3J3l _ <br />Policy No. Effective date of coverage _ <br />Amount of coverage: Public liability, per person, per occurrence $ <br />Public liability, per occurrence $ .Kbo. c>o£> ±_ <br />Page 2 of 5