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r <br />5. <br />6. <br />7. <br />8. <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 <br />Names of abutting lakeshore property owners: <br />fNorth/WesO C/cTT ^ Q <br />(Nami + (Address)t,iNam« +t>\aaress; ^ ^ f ] <br />(Name + Address) <br />Names of other affected property owners; <br />___________ A <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 informatiom^ /- <br />Name of insured ( • <br />Name of insurance carrier <br />Name of insurance agency r g~T~ <br />Policy No. ^ ^ Effective date of coverage <br />Amount of coverage: Public liability, per person, per occurrence $ li^ily <br />Public liability, per occurrence $ / /w \([*, . <br />Page 2 of 5