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` ' 3 <br /> � OliONO <br /> CITY of <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offic� <br /> • <br /> � _ � � On the IVorth Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we would like to inform you that your request for a permit or <br /> license f rom the City o r�ate r confident al e nfornnationmay require <br /> you to furnish certain p <br /> You are notified that: <br /> 1. '1'he iniormati�a you furzish wi3_1 be used to determine your <br /> qualification for the permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared with oth=�r e scthe perm�t or <br /> federal agencies to the extent necessary to p <br /> license. <br /> 4. If your requested permit or license requires Councii actior. <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�e <br /> data on yourself. . <br /> 6. Your full name is reguired to proc�ss this application or <br /> permit. <br /> Pe�e t- So�+r� �-��� \1 <br /> First <br /> Middle Last <br /> S , S � � C 0.,,�r1 � � <br /> Address <br /> � a�.Za�a- Mr� SS� <br /> City State Z1p <br /> ��l S-q3�{ � <br /> Phone <br /> I underst my r h as stated above. <br /> Signature � <br /> BUILDING&ZON[NG-473-7357 • ADMINISTRATION&FINANCE-473-7358 <br /> • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />