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! <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 ^oTS 12^'^ ^ ^ <br />Legal property description //JAj tA__________________ <br />PiD/5^ ______________________________________________ <br />1 <br />Listed property owner(s) <br />^^c^cs/a^j SS‘I <br />7 <br />Names of abutting lakeshore property owners: <br />(NorthAVesfi <br />(Name + Address) <br />fSouth/EasO /J/A _____________ <br />(Name + Address) <br />Names of other affected property owners: <br />________________________ <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. ^-‘2^^'^- Effective date of cr /erage <br />Amount of coverage: Public liability, per person, per occurrence $ /. QO^ <br />Public liability, per occurrence $ /» <br />Page 2 of 5