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. <br /> ' � � <br /> ` � (����.' o� ��►�11T� <br /> Post Office Box 66•Crystal BaY,Minnesota 55323•Munidpal Offices <br /> � On the North Shore of Lake Minnetonka - <br /> • ' � • <br /> DATA PRSPACY ��SORY <br /> "Rights of subjects of <br /> In accordance with M.S. 13•ou'that yonr request for a permit or <br /> we would like to inf orm Y of its departments may require <br /> data", o f Orono or any <br /> license from the City <br /> you to furnish certain private or confidential information. <br /> You are notified that: - <br /> 1. The information you fur oZ iiCensebrequest�d. aetermine you= e <br /> erma.t <br /> aualification for the p require that <br /> refuse to supply data, but refusal may <br /> 2. You ma.Y e�it or license. - <br /> the City deny the p � <br /> be shared with other local, s�ate or <br /> 3, The inf ormation maY rocess the permit or <br /> f edera3. agencies to the extent necessary to p <br /> license. <br /> our requested permit or Iicense requires Council ac�=or_ <br /> a, If y become public. <br /> to aporave, 5ome inf orncation maY <br /> �. You have certain rig <br /> hts under M.S. 13.04 to review priv��e <br /> data on yourself. <br /> 6, Your full name is required to procsss this application or <br /> p e�-mit. <br /> �Q f�v� �r�-�-GL �Zi <br /> 1� � Last <br /> Firs� Middle <br /> ���, ,�.,� �� � �-h . <br /> Address �5�� � <br /> ��� �z� � <br /> City <br /> State Zip <br /> LI� '��cJ� . <br /> Phone <br /> I understand my rights as stated above. <br />>, <br /> Si ure <br /> - • PUBLIC WORKS-473 7359 <br /> BUILD[NG&ZONING-473-7357 • ADMINISTRATION&FIN.�NCE-3�3'�358 <br /> ASSESSING <br />