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: + ""' <br /> � ����' o� ���N� <br /> Post Office Box 6&•Crystal Bay,Mi.nnesota 5�323•Munidpal Offices <br /> M . <br /> ! _ <br /> On the North Shore of Lake Minneto a <br /> • ' • • <br /> DATA PRNACY A��S�RY <br /> Subd. 2, "Rights of subjects of <br /> In accordance with M.S. 13•ou�that your request for a permit or <br /> we would like to inf orm Y of its departments may require <br /> data", o= Orono or any <br /> license from the City <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> l, The information you fur or li ensebrequested, Qetermine yaur <br /> qualification for the permit <br /> 2. You may refuse to SL1DpI-Y <br /> data, but refusal may require that <br /> tne City deny the permit or license. <br /> 3, The information may be snared W'-tht�°P=oc sscthe pe=mit °r <br /> f ederal agencies to the extent necessary <br /> ?icense. <br /> our requested permit or Iicense requires Councii ac�tor. <br /> q, If y become public. <br /> to aporove, some information maY <br /> 5. You have certain rights under M.S. 13.Oa to review private <br /> data on yourself. <br /> 6, Your full name is required to proc�ss this application or <br /> pe�it. <br /> �B B�"Q � �/� � �-- /�c��-t��� , <br /> Middle Last <br /> First <br /> � � a o �����2�����C p �� � <br /> Address G'y( �s 3 a1 <br /> /`�/Y 0 � Z i.p <br /> City <br /> State <br /> �T3-�3 �` . <br /> Phone <br /> I understand my rights as stated abOVe• <br /> r� . <br /> ignature � <br /> - • PUBLIC WORKS—473-7359 <br /> BUILD[NG&ZONING—473-7357 • ADMINISTRATIOtY&FINANCE—;�3'�358 <br /> p55ESSING <br />