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` <br /> � <br /> ____�_ <br /> � � <br /> � <br /> O _.-_ o ���� <br /> ��'��' �f � <br /> � , ;;:�, ,,,, ,i���►o� <br /> r�' <br /> '•, � ;. �'., Post Of6«e Box 66 <br /> `'�,� , , ��.' - '� ��' Crysial Bay,�linnesota�53Z�OObb <br /> �9kESH�4� <br /> DAT� PRIVACI' ADVISORY <br /> In accordance «�irh �i.S. 13.0�> Subd. ?. "Ri�hts of subjects or daca", �ve would like to <br /> inform you that your request ror a p�:mit or license irom the Cicy of O:ono or any of its <br /> depanments may require ��ou �o :�s�sn cercain pri��a�e or conridential intormaLion. <br /> You are notiiied that: <br /> 1. The info�-rnacion ��ou �srnish will be used to determine ��our qualification for the <br /> permit or license reauested. <br /> ?. You may refuse to supply data, but refusal may require that the City der.y the <br /> pernit or 'icense. <br /> 3. The information may be snared with other local, state or federal aQencies to tr:� <br /> extent nece55ary to o.o::ess «�� PerM�t or licer.se. <br /> 4. If ��our :equested �e:mit or license requires Council action to approve. sorrie <br /> inrormacion may becom� DUDIIC. <br /> � You have ce-:ain ri��ts under ��1.S. 13.04 (see fo!Io�j�inR p3Q�) to review private <br /> data on �ourseLf. <br /> 6. Your iull name is :equired to process this applicacion or permit- <br /> PL�asE P�rr <br /> , � _ , <br /> � �� <br /> � � _� f �G'�: - i i <br /> First <br /> � �r1�dd:e L35t <br /> � <br /> � _ , i'' � <br /> r � p i!p -i, _ <br /> .address <br /> r� <br /> �-. �.s � '7 _/ �/J'� � <br /> _'�- : .� �� - j. <br /> .�� .. ,. �� - � � � � <br /> �-� . � �" Stace Zip Phone <br /> C1N <br /> I understand my riahts as srated above. <br /> � , <br /> � <br /> �. <br /> Sianacure <br /> v TELEPHO?V�-�373-1357• FAX-�373-0510 <br />