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:_—� _ <br /> /� � � <br /> � '.� � �� <br /> - ����" �� ��O <br /> �3 '-'`�.- _ >, �t���ot� <br /> �` � ! - E� Po�oer�saX� <br /> 'r'.�, . ; ,�, ;- :•: G•�, c��say,«;�ta s��-oo� <br /> l � ' . �� <br /> �kESH�� <br /> ,, <br /> DAT:� PRIVaCY ?iDVISORY <br /> In accordance wirh `i.S. 13.0-�. Subd. ?. "Rivhts oi suojec:s ot� data". we �vould li�:e to <br /> inferm ��ou that your req_uest ior 3 D�rrnit or license irom th� Cir�� oi O:ono or any oi i�s <br /> depanments may require vou to �1�-nish cercain pri��a�e or coruidential inr'orrnation. <br /> You ar� notiiied that: <br /> l. The informa�ion ��eu �srni�h tviL be used to de�ermine �'our ouaiirication for the <br /> permit or license reauested. <br /> ?. You may reruse to suopl�� daca, but renisal may require that the Ciry der.y the <br /> pernit ar �icense. <br /> ;. The inTormation may oe snared «�ith other local, state or iederal aaencies to the <br /> �xtent necessary� tJ Dr��ess ���� pe:m�� oi license. <br /> �. If ��our requested pe:mit or license requires Council action to aoprove. sorrie <br /> intormation mav becom� pu�lic. <br /> �. You ha��e ce;�ain ri��ts und:.r ��I.S. 13.0^ (se� fo?lo<<�inR p3a=) to revie�v private <br /> data on ��ourszlf. <br /> 6, Your fu11 name is r�quired to process this appiication or permit• <br /> PLE�SE PRL�'T <br /> � , � . �j ��'\ `5 fl <br /> __ ��i;dd;e Last <br /> First <br /> �' �'� \,v ���_ � <br /> .�,ddress <br /> Gi�'�j�`7(�, ��-�� � �O l�'� <br /> ���`��F`� �`� ' <br /> Ciry <br /> Scate Z.p Phon� <br /> I understand my riQhts as s�ced above. <br /> � , __ � �- <br /> � � � ' �� � � , <br /> , <br /> Si_ a z � <br /> �_ TEI.EPHO?��E-373-T357 • F.�..Y-�i73-0510 <br />