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5. .. ~rincipal purpose of joint use dock is (check applicable items): <br />6. <br />provide boat mooring and lake access for residential property. <br />· · · · provide swimming access, beach, or offshore dock. <br /><Y,.. 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 />7. List Dock location and ownership information: <br />Street address 5 IO B '.'9 Is la O d <br />Legal property description B, 9 Is land) Recor: d bf2± ~ <br />P I D # Ji(A -I I 1 -d 3 14 00 Ob <br />Listed property owner(s) mi r1 ne. 'fon ku YOW er s~ u4dro t] <br />8. Names of abutting lakeshore property owners: <br />; (North/West) <br />(Name + Address) <br />(South/East) <br />(Name + Address) <br />Names of other affected property owners: <br />(Name + Address) (attach sheet if necessary) <br />9. Insurance Coverage -The jointly used dock is insured by one of the following: <br />property owner's homeowner's policy. <br />X separate group/association owned policy. <br />List the following information: <br />Name of insured /'n in(\ e_ + on ka row er Sg u ad ro n <br />Name of insurance carrier · & RE .In Suro n<le G tou42 <br />Name of insurance agency Jn5U.tQYJ(le lfc/01~or.s J/Je, <br />Policy No. 85 -30o B 'f~ Effective date of coverage 7 /30 /q 3 <br />Amount of coverage: Public liability, per person, per occurrence $ 500, 00 O <br />I <br />Public liability, per occurrence $ 5()(),DOO <br />Page 2 of 5 <br />~-""' . ... ,.._.,.