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� <br /> � _ -�_Y <br /> ' /�__, <br /> � � " r <br /> � � - � NO <br /> ---- G ITY of 4R0 <br /> ,� ;,:, ;';;�: _ � ��,��o� <br /> ` ' .:�. �., Posc office sox 66 <br /> `�``�,� �i:•'�l .+ -_ �:� �'�' Crystal Bay,�linnesota��2.3-0066 <br /> ; l •';I.._. _ �-� <br /> ' ������ <br /> �� <br /> DATA PRIVACY ADVISORY <br /> In accordance �;�ith �i.S. 13.0�, Subdor licensetfroms thee CiryTotatO:ono or�an io e o <br /> i n fo r m y o u t h a t y o u r r e q u e s t r o r a p�r m <br /> departments may require ��ou co furnish cercain priva�e or co�dential information. <br /> You are notified that: <br /> 1. The information you furnish «�ill be used to determine your qualification for the <br /> permit or license requested. <br /> ?. You may refuse to suopl}� �'ata, but refusal may require that the City deny the <br /> pernit or license. <br /> 3. The information may be shared ��ith other local, state or federal a�encies to t?�.e <br /> extent necessary to pro��ss �ilz perr��t or license. <br /> 4. If your requested permit or license requires Council action to approve, some <br /> information may becam� public. <br /> �, You ha��e cer:ain ri�hts under M.S. li.04 (see fo?]o�z�ina pa�e) to review private <br /> data on yourself. <br /> (. Your full name is required to process this application or permit. <br /> PLEASE PRL�T'T <br /> /� �r � c�cY c+/ -PrM ti' 2 v— <br /> First �iiad:e Last <br /> �-o� �y.�., o.. � c. �ak d <br /> Address <br /> ��, S-�'.3 r �l-7S`� r�o� <br /> °�` `� Zip Phone <br /> C iry S tace <br /> I understand my rishts as sta�ed above. <br /> 0 <br /> , � <br /> Si�nature <br /> ��orrE-a��s�• Fax-a�-osio <br />