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mi,’& .. <br />f 'i € <br />i. <br />iv- <br />vIE=^ <br />aFF€ii^*Ge- <br />CITY of OEONO <br />Pom Offic* Box d6«Crynai Bay. MianaMca53323• Muaidpai OfEUxa <br />On tht North Short of Lake Minitetonka <br />DAT& Parw^CY ADVISOR? <br />. ; ■: * <br />K ;■r' <br />la aeeordanca with M.S. 13.04, Subd. 2, "Sights of subjocts of <br />~ a.‘=“ V.%you to furnish co-rtnia privats or confidential information. <br />U: <br />I ■• <br />S--' <br />k- <br />V>» <br />You are notified that: <br />1. The information you furnish will be used to determine your <br />qualification for the permit or license requested. <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 other local, state or <br />federal agencies to the extent necessary to process the permr- or <br />license. <br />, ;v <br /># <br />K <br />#■■/M <br />:5 <br />4, x£ your requested permit or license retires Council action <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 />; • ■■■ <br />• T... <br />■‘:v <br />I# <br />a: •••■'I <br />\¥'-' f. <br />First Middle Last <br />A 0dK /(fO <br />Address <br />(£^1. <br />state <br />yhone <br />'«i- - <br />- • <br />v'Hi'ii' <br />Z "T*de*^*t*"** my rights as stated above. <br />.gxMture <br />iuiLaeiGa zof«iric - vwyan A£MINirntATION 4 FINANCE - 473-7358 PUBUC WORKS - 4 7 3-735 9 <br />ii.5-5'