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5. <br />6. <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 />X 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 TKg^ ps-rf ^ <br />PlDff _____________ <br />Listed property owner(s)_____ <br />8.Names of abutting lakeshore property owners: <br />(North/West) ___ <br />(Name + Address) <br />fSouth/EastI <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 />• • <br />y 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 C i h Cfi <br />Name of insurance agency ________________ <br />Policy No. Effective date of coverage ____________ <br />Amount of coverage: Public liability, per person, per occurrence $ IC^() j cOO <br />Public liability, per occurrence $ 100) (X^ <br />Page 2 of 5