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- ' ' 10i18i94 16:26 THE CITY OF OR�JO 612-473-7357 003 <br /> . -� <br /> c�T� of o�o�va <br /> Post Uttta Box 66•CrYstal Bsy,Minnesots�SS23•Manjdpsi 4P�ee� <br /> • <br /> � � • � On the North 9hort of Lake Minneto�eka <br /> DATA PRISTAC7� AD�ISORY <br /> In accordanaa with M' orm3�ou�that your requeat fcrsa permit or <br /> d�ta". we would Iike to inf Y re uire <br /> IiaenSe g aish ceztain private or cont�denti 1 informationmay q <br /> you to fur <br /> You are notified that: <br /> 1. The inf orma��i thQY ermit ar Ii ensabrequestAd� determine your <br /> qualif3cation f P <br /> 2. You atsy refuse to suppl.y data, but r�fusal may z'equire that <br /> t1�e, City deny the permit or licsnse. <br /> 3. 2he ingormatiivn may be shared with other Iocal, state er <br /> fed�ral aqencieS tv the extent necessary to proeess the permit a= <br /> licease. <br /> 4, If youz requ�st o ation aiay be ome publ�ic r�� Councii action <br /> to appzove, some �.nt <br /> 5. You have certain rights under M.S. i3.04 to review priva�e <br /> data on yourselt. <br /> g, your full name is required to procsss this app].ication or <br /> permit. �/7 G/(��f� ����a/� <br /> �' � r <br /> ,� / - <br /> First <br /> Mid le Last <br /> �/Od ���'�S�'l��'� ��'1 <br /> Ad ress ���/�/ <br /> `7 Y <br /> Cit <br /> State Zip <br /> �i�- 551.�- 7�/� <br /> Phone <br /> I understand my rights as statsd above. <br /> . � <br /> Sig ature � <br /> BUILDING�ZONING-d73•7357 • ADMINISTRA7'tON�FiNwNCE-47J-7358 <br /> • PUBGIC WORKS-473-7359 <br /> ASSESSiNG <br />