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T <br />* ■ i <br />y <br />mi <br />\r. . <br />‘LiI <br />P4TAPWIVAC Y ADVISORY <br />4_. - •ooorttanoB with M.S. 13.04, Subd. 2, TIIbMb of subjects of dcrta", we would like <br />leiiinTOyoM that your iwiuast for a permit or license from the City of Oiono or any of Its <br />«B«1monls may require you to furnish certain private or confidential kifbrmation. <br />You are notified that <br />1. The Inffwrwatiwn you fUmbh wM be used to determine your niia Hfj <br />the permit or Hcanse requested. <br />I •nfor <br />2. Y^ may rehise to supply data, but rehisal may require that the City denytm pofvnil or Ho6fise. <br />3.The Information may be shared with other local, state or federal agendas to <br />the extent necessary to process the permit or license. <br />If your requestad permit or Noense requires Council <br />information may become public.n to approve, some <br />5.Ywrlmve certain rights under M.S. 13.04 (see following page) to review <br />6. <br />.Brad. <br />Your foil name is required to process this application or permit <br />______________M- _____^JonesFirst <br />_124SVifoodhMAve <br />Middls Last <br />Address <br />^Whyzatta <br />City MN <br />State <br />55391 <br />Zip <br />952-476-0819 <br />Phone <br />I understand my rig <br />SIgnatu <br />» j I <br />8 <br />O “Ii-a. <br />Qo <br />‘i