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. , <br /> , • -� <br /> -==� , <br /> � � � <br /> O - =.: � ���� <br /> C�T�i' Of � <br /> ,� ; i,:�:- _ �., �t��at ot�c� <br /> ,�. i E'y Post O�ce Box 66 <br /> ` `'�,� `::,ti. '-. �� �ti' Cn•stal Bay,�Iinnesota»3�0006 <br /> �.. ''� � r <br /> ��kESK��� <br /> ;��.:. <br /> DAT� PRIVACY ADVISORY <br /> In accordance «�ith ��T.S. 13.01, Subdor license[iroms the CiryTo a O:ono or andylofe it� <br /> i n fo r m y o u c h a t y o u r r e q u e s t r o r a p�r m <br /> departments may require ��ou to turnisn cenain private or confidential iniormation. <br /> You are notified that: <br /> 1, The inforrria�ion ��ou furnish «�ill be used to determine ��our qualification for the <br /> permit or license requested. <br /> �. You may refuse to suppl}� data, but refusal may require that the City der.y the <br /> pernit ar 'icense. <br /> 3. The information may be shared �vith other local, state or federal aQencies to the <br /> exter�t necessary �o process �:�� �e:ra�c or license. <br /> �.. If your ;equested permit or license requires Council action to approve, some <br /> intormation may becom� auolic. <br /> � You ha��� ce;:ain ri�hts una�r N1.S. li.0? (see fo!lo���in, paQ�) to revie�v private <br /> y data on ��ourself. <br /> 6. �'our full r.ame is reauired to process this applicacion or permit. <br /> PLE�SE PRL'�'T <br /> /Oh�i✓ C�-�� .. �.�/,qL. s T E 1> i <br /> First '_vlidd:e Last <br /> 3 �j D i�1S/,D� �0�4� <br /> ,�ddress <br /> D,�o�o ��.�� ss3.�� ��s-0 9� <br /> C1N <br /> S�ate Zro Phone <br /> I understand my riahts as staced above. <br /> i�nanire <br /> `� rE�xo!vE-ar3-�s� • e.�.x-ar3-osio <br />