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� 3 1� <br /> '/ € _. <br /> ��� CL� <br /> �- � ����' o� ����T� <br /> � . post Office Box 68•CrYstal Bay, Minaesota 5a323•Municipal Offices <br /> N■ <br /> ! - <br /> On the North Shore o�Lake Minnetorz a <br /> o - • • <br /> DATA PRI��� ��SORY <br /> � Subd. 2, "Rights of subjects oi <br /> =n accordance with M.S• Z3'ou�that your request for a per�it or <br /> we woul.d like �o inform y oL its departments may require <br /> �=�`a�' oz Orono or any <br /> :L�.cense from the City <br /> vou to furnisn certain private or confidential inrormat�.on. <br /> you are noti�ied that: <br /> i be used to determi.ze your <br /> 1. Tho information you furnish wii� <br /> cualificatien for the per.ni� or license recuested• <br /> 2y ouu �ay retuse to supply <br /> data, but resusal may require that <br /> -r-*�it or license. <br /> the City deny the pe-��• <br /> ; n_ormation may be snared w�th ot:�e=' local , s�a�e or <br /> 3 . The r o to process t'tie perni.� oi <br /> federa.l agencies to the extent nec�ssary <br /> �icznse. • <br /> yod pennit or iicense reQuir=s Counc�.i ac��or <br /> �, your reques�_ , become pupZic. <br /> to aperove, some intorma��on may <br /> You have certain rights under M.S. 13.Oa to review �riva�e <br /> data on yourself. <br /> 6 . Your fu?1 name is recuired to process this applicat=or. or <br /> pernit. <br /> � �� ���_�;�-(,�. <br /> � �i �(��� �Gt r'?,(� � <br /> _ - Last <br /> y riiddle <br /> Firs� .�� <br /> ' ;� �,�� <br /> �' �C�' �������� �;ti.,L-,_�� � <br /> Address �� ,� �, / <br /> � �� v �, j I�'U vV <br /> , �� � Zi.p <br /> � State <br /> City � � �, �,��� <br /> �� � <br /> Phone <br /> I understand my rights as stated above. <br /> ,� ��--. ----- __ _ _ <br /> .; - <br /> �- _ <br /> � �-- <br /> - — <br /> . _-- , <br /> ��_--__ --_ _. . <br /> Signature - �- . <br /> =UILD[NG&ZONING-473-7357 • ADMINISTRATION&FINANCE-�73'�358 <br /> � PUBLIC WORKS-473-7359 <br /> ASSESSING <br />