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� � ' <br /> �/ ' � f�l <br /> � ' V <br /> O -; � ���� <br /> ����' o� O <br /> ,)i �::�. ,�.,, �iunkipa►offices <br /> � - �'y Post Offic�e Box 66 <br /> '� ta 55323-a06G <br /> �,� , ;,�S; - :� �`�' Cr��stal Bay,�linneso <br /> � . � ' "� � �� <br /> �kESH�4 <br /> �__ : <br /> DAT� PRIVACY ADVI.SORY <br /> In accordance with �S.S. 13.0-�> Subdor lic nsetiroms the Cicyrot LOrono or�anylot�i� <br /> inform ��ou that vour request ror a p�rmit <br /> departments may require �rou �o i�srnisn c�rtain pri��ate or contidential intormation. <br /> You are notiiied that: <br /> 1. The info:�nation ��ou rsrni�h will be used to determine �'our quaiification for the <br /> permit or license requested. <br /> ?. You may refuse to suppl}� data, but rerusal may require that the Ciry der.y the <br /> pernit or 'icense. <br /> 3. The L�tormation may be shared with other local, sta�e or federal aaencies to t?:e <br /> exter,t necessary to p.'J��ss «j� Pz:��t or iicer.se. <br /> ?, If ��our requested pe:mit or license requires Council action to approve, sorrie <br /> information mav beccm� puolic. <br /> �. <br /> You ha��e ce;�ain ri�hts under ;��I.S. 13.0? (see fo�lo���in� p3a�j to revie�v priv�te <br /> data on yourszlf. <br /> (. Your fu11 name is :eauired to process this application or permit- <br /> PLE��SE PRL\''r <br /> �� � • � <br /> � � r�j � �e;� <br /> `�� ��liddle Last <br /> First - <br /> �' �� \v ��� ���e- ='� <br /> .-�ddress - <br /> ,�-� � � �"-,j"������� -, /��� — ��l-�'� <br /> ��'`"�'� '`�� Zip Phone <br /> City State <br /> I understand m}� riQhts as staced above. <br /> � � � <br /> > <br /> ��� " � `. � `— <br /> Si_ a � �e� <br /> � TEI.EPHO?YE-�373-7357• EAX-�173-0510 <br />