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, � .. <br /> �-�� ���� <br /> �j' �3. ��"� J�: �-r mv AT O <br /> t . � y�r ��x . : lJ� i 1 O� ���1� <br /> � <br /> s ,.t ��{y,� ,+ .rt`„s�=:3 <br /> iJz.*dX'T}�i'�itKp r�'��L{µ�. <br /> ..!iM.h 1 i Ja.. <br /> ,.,.,;.;, , 6:�-��' Post Office Box 66•Crystal Bay,Minnesota Sa323•Municipal Offices <br /> ..,w . . ,-�:;� <br /> �i� -�r��,�'y`� <br /> u'.,:,.. � ,1,,,�,,,r,,cay;,. <br /> =�`�' �' On the North Shore of Lake Minnetonka <br /> ' � � A �;., <br /> DATA PRNACY 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 fro Sri certain pr�ate or conf dentia le nf rmationmay require <br /> you to furni <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your <br /> qualification for the permit or Iicense 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 other �ocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�� <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> T <br /> / ] � � <br /> � �� � lfC�`-� 7 rf. i <br /> Fir Middle Last <br /> �� y� � �' , <br /> Address <br /> � � � f�- r � ��r <br /> �� lr � . � <br /> City State Zlp <br /> ��/.i. .,_ �;i�� / <br /> L <br /> Phone <br /> I understand my rights as stated above. <br /> � • ,,� i <br /> � ..,� <br /> Signy�- ure � <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—�73-7358 <br /> • PUBLIC WORKS—473-7359 <br /> ASSESSIN G <br />