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�- <br /> �.�. �- ��t��" o� ����T(� <br /> N� <br /> Post Office Box 66'Cr5'stal Bay, ��o�5��•M�ap��� <br /> � ! - <br /> Qn the North Shore of Lake Minneton a <br /> • - • • <br /> DATA PRNACY ��SORY <br /> Subd. 2 , "Rights of subjects of <br /> ou that your request for a permit or <br /> Ins,,�e wouldnlike1to nform3yo � require <br /> data", o= Orono or any of its departments may <br /> license from the Ci�Y rivate or coniidential in=ormation. <br /> you to furnish certain p <br /> You are notified that: <br /> 1, The information you furnish wiZl be used to determine your <br /> cualificat=-on for the per:nit or license requested• <br /> 2. You may <br /> refuse to supoly data, but rerusal may require that <br /> tne City deny the permit or license. <br /> be snared with oth�=" local , s�ate or <br /> 3. The information may to process the permit or <br /> f ederal agencies to the extent necessary <br /> license. <br /> Iicense reQuires Councii ac�'-or <br /> �_ li your recuested pe'-�n1t or - <br /> `o aporove, some in�ormat-on may <br /> become publ.ic. <br /> J� <br /> You have certain rights under M.S. 13.0a to rev_ew private <br /> data on yourselz. , <br /> �, <br /> 6 . your full name is required �o proc�ss this apol�ca�_or. or <br /> pe,-.nit. <br /> , 1 <br /> � ;, �1 k. <br /> � -� 1�� �� <br /> Middle Las� <br /> r^irst <br /> �/ <br /> :� 5 �� Cj n.��.t C P J � <br /> Address � <br /> � �� i �j S-3 G`''`� <br /> � G \ State Zip <br /> City <br /> �, <br /> � <br /> y7/ '�� � - <br /> Phone <br /> I understand my rights^ as stated above. <br /> � <br />� �� . - '� � <br />� �.c-� ��� U� � . <br /> Signature � <br /> � pDMINISTRATZOH&FINANCE—473-7358 <br /> • PUBLIC WORKS —473-7359 <br /> BUILDING&ZONING—473-7357 <br /> ASSESSING <br />