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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 />y. provide boat mooring and lake access for residential property. <br />y 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 />y property owned by the group/association <br />List Dock location and ownership mformation: <br />Street address _____ <br />Legal property description <br />PID# _________ <br />!tZ <br />Listed property owner(s) <br />Names of abutting lakeshore property owners: <br />fNorth/West) <br />Name <br />Ucl)ir <br />f'Snuth/East) <br />(Nanle + 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 ^aaaau. <br />Name of insurance carrier_____________________________________ <br />dS <br />Name of insurance agency <br />Policy No. ___________Effective date of coverage <br />Amount of coverage; Public liability, per person, per occurrence $ <br />Public liability, per occurrence $ <br />Page 2 of 5 <br />_J