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- •i; <br />` ` � �i��� �� ���N� <br /> Post Office Box 66•Crystal BaY,Minne"'ota Sb323•Munidpal Offices <br /> M ' <br /> � On the North Shore af L�e Mirusetonka ' <br /> • ' • • <br /> DATA PRNACY ��SORY • <br /> � "Rights of subjects of <br /> Subd. 2. ermit or <br /> In accordance with M.S. 13•ou'that your request for a P uire <br /> data", we Would like to inform y o f its departments may req <br /> of Orono or any �n=o�ation. <br /> license from the City rivate or coniidential <br /> you to furnish certain p <br /> you are noti�ied that: - <br /> e iniormation you furnish censebrequest a, aetermine your <br /> 1. Th e�i� or li <br /> cualif-�a�=on for the p uire that <br /> refuse to supply data, but refusal may req <br /> 2. You may the per�it or license. <br /> tne City deny � <br /> be snared with oth�r local , s�ate or <br /> 3. The information maY <br /> rocess the permit ai <br /> f ederal agencies to the extent necessary to P <br /> ?icense. , ac��o% <br /> a If vour reques�ed pe="m1t °r Iicense r�elauc r�s Councii. <br /> n=o� ma become p <br /> to apgrove, some i ation Y <br /> - have certain rights under M.S. 13.04 to review priva�e <br /> �, You _ <br /> data on yourself. <br /> 6, your full name is required to proc�ss <br /> this application or <br /> per,nit. <br /> ��,��r T <br /> �-,�vrr� �c��r� Lzs� <br /> r^isst <br /> Midd?e <br /> ���-�� �iinrr- C I�C L F <br /> Address SS3�`i <br /> O2U� N Z ip <br /> State <br /> City <br /> �`72 � `�g�� . <br /> Phone <br /> I understand mY =ights as stated above. <br /> f � ' <br />� <br />� � • . <br /> Signature <br /> BUILDING&ZO`jiNC-4'73-7357 • ADMINISTRATiON&FIN�CE-;73-7358 <br /> � PUBLIC WORKS-473-7359 <br /> ASSESSING <br />