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i 5. <br />6. <br />7. <br />8. <br />^SS(P( <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 />T <br />____ property leased by the group/association. <br />____ property owned by the group/association. <br />List Dock location and ownership information: <br />Street address________________________ <br />Legal property description AoT" <br />PIDij' <br />Listed property owner(s) <br />Names of abutting lakeshore property owners: / <br />(NorthAVest) S/7n//ev/ *7/130 <br />• (Name + Address) / <br />fSoulh/EasO pcCig «?io S.S- ZfiOO 7^cvaS/i.gfr /d), <br />(Name *+ Address) <br />Names of other affected property owners: <br />€.kfn<^L)^ Z999 0t^/}^^rSr ______ <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_____ <br />Name of insurance carrier <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