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5. <br />6. <br />7. <br />8. <br />9. <br />Principal purpose of joint use dock is (check applicable items): <br />X 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 />X 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 />List Dock location and ownership information: <br />Street address 500 Tonkawa Road <br />Legal property description NW 1/4 - SW 1/4, Section 5. Township 117. Range 23 <br />PID# ___________________________________________________________ <br />Listed property owner(s) Dr. Glen D. and Marilyn C. Nelson _______________ <br />Names of abutting lakeshore property owners: <br />fNorth/WesQMr. S Mrs. Edwin C. Gage. 460 Tonkawa Road. Long Lake. MN 55356 <br />(Name + Address) <br />(South/East>Mr. S Mrs. Curtis L. Carlson. 550 Tonkawa Rd.. Long Lake, MN 55356 <br />(Name + Address) <br />Names of other affected property owners: <br />________________________None ___________________________________________ <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 Dr. Glen D. e Marilyn C. Nelson ______ <br />Name of insurance carrier The American Insurance Co.__________ <br />Name of insurance agency Harris Homeyer Co., Edina, MN 55424 <br />Policy No. NZA1319205_______ Effective date of coverage 6/31/94 <br />Amount of coverage; Public liability, per person, per occurrence $______ <br />Public liability, per occurrence $______ <br />Page 2 of 5