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5. 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 /> 6. Dock is located on (check applicable item): <br /> one member's private property. <br /> � �or outlot owned in common. <br /> property leased by the group/association. <br /> properry owned by the group/association. <br /> 7. List Dock location and ownership information: <br /> Street address ��-g7- 2�03 �L�.1,�� �}1/�'NU�!, EXCk�slOR, N(N 5's"331 <br /> Legal properiy description 4 u�a� /�. K�'L�`/ C O VL= <br /> PID # �D- ll�f- �3 !� boS� � <br /> /�vSTi�r M-.�r 14N4' CYf�/,r��,tflN A k'vPt=HYi <br /> Listed property owner(s) -Toy��c ��rN�rn� TaN�s .►,.vcs�R�� �V�lu N»�G.�► � <br /> Tb�A�vAuNL�TTS �K� C .1`'�A-t�; <br /> R�cr�eD �.����.a.��MAtT Yk�+�oR wSY4V�N A, et�i734r�reL+o iys caw�-+aRci V�K��`� <br /> 8. Names of abutting lakeshore property owners: <br /> (North/West) No T xNo w nl <br /> (Name + Address) <br /> South/East Q R A�i.ra .l�o ' ?S3 k� A�� S�'�"f Z9779 MN S S'� / <br /> , (Name +, A dress) <br /> Names of other affected �roperty owners: _ , <br /> . -• , , :, <br /> C N+gR/.k�'k��AN.D/tE N/4,�1L%�. ��o�j k�7.�y /�v�7vu,�, �q,p(cr"�S�oR MN S S"3 3/ <br /> (Name + Address) . (attach sheet if necessary) <br /> 9. Insurance Coverage - Th�jointly used dock is insured by one of'the fbllowing: <br /> property �owner's homeowner's policy: �� ` t'. � <br /> � separate group/association owned`policy. � � <br /> List the following information: <br /> Name of insured k�-�c� Gov� f�i�roww-�2s qssoc�g��av o� QRoNo <br /> vNd r�2 Name of insurance carrier �tµ� C�N C�lNNA;�� co�tP�v��S " ' <br /> pPPt�c�s�o� Name of insurance agency �Rg,�r�' i3 vu.r S !9�Nc�l <br /> Policy No. �oTy� k�✓a,.�/ Effective date of coverage <br /> Amount of coverage: Public liability,per person, per occurrence $ /,soa, e�o <br /> Public liabiliry, per occurrence $ j�p O O, o 0 0 <br /> Page 2 of 5 <br />