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r <br />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 />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 S'j 0 & I Cr <br />/¥ <br />Legal property descnptjon <br />PID# ^ ((1“~ "X 3 <br />Listed property owner(s) <br />8. Names of abutting lakeshore property owners: <br />(Name + Address) <br />(South/](Name + Address) <br />Names of other affected property owners: <br />----------------(Name + Address) (attach sheet if necessaw ^ <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: a j/ <br />Name of insured <br />Name of insurance carrier <br />Name of insurance agency <br />Policy Effective date of coveragePntinvNo^<r-3;9Z)^/_^_____ ^ <br />Amount of coverage: Public liability, per person, per occurrence <br />Public liability, per occurrence $ 0(P\ 0Q __ <br />Page 2 of 5