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I <br /> �1 < = i <br /> l Np � <br /> C ITY of OR4 , <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offi� � <br /> • � <br /> � � � � On the North Shore of Lake Min.netonka <br /> DATA PRIVACY 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 from the ta n � r vate or conf dentialeinformationmay require <br /> you to furnish ce p <br /> You are notified that: <br /> 1. The information you f�or?i ensebrequested. determine your <br /> qualification for the perm i <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 oth�eocesscthe permit or <br /> federal agencies to the extent necessary to p <br /> license. <br /> 4. If your requested permit or Iicense requires Councii ac�ion <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6, Your full name is required to process this application or <br /> permit. ' <br /> ��35�`� �l ���a� l6`1 Gi so `► <br /> First <br /> Middle Last <br /> S� 3� V�,�'H�ti �-'�� , <br /> Address <br /> ��i q �/� �Sy3� <br /> City State ZlP <br /> 9� 7 - 5� 9� � <br /> Phone <br /> I understand my rights as stated above. <br /> li�- — '' <br /> Signature � <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 ' <br /> ASSESSING <br />