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� <br /> ~Y ' � �`���� �I'�Y Of ��O�T(� <br /> :*��t �Y <br /> #�1 K v <br /> F {a� k'�i ;,' <br /> +�,�� �����^�! '. <br /> �- <br /> -+ .r�"', � Post Office Box 66•Crystal Bay, Minnesota a�323•Municipal Offices <br /> � <br /> • <br /> � _ � s On the North Shore of Lake Minnetonka <br /> i' <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04 , Subd. 2 , "Rights of subjects of <br /> data" , we would 3.ike to inform you that your request for a permit or <br /> license from the City of �ate orrconf dential. ei f r.nationmay require <br /> you to furnish certain pr <br /> You are notified that: <br /> l. The information you furnish will be used to determine your <br /> qualification for the permit or Iicense requested. <br /> 2. You may reiuse to supply data, but refusal. may require that <br /> the City deny the permit or license. <br /> 3. The inforination may be shared with other �ocal, state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your reauested permit or Iicense requires Councii action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�� <br /> data on yoursel.f. <br /> 6, Your full name is required to process this applica�icn or <br /> permit. <br /> �o�Jn� /� R.Ti�✓ �,"l ss <br /> First <br /> Middle Last <br /> /� �.ecsW.cJ �',� S <br /> Address <br /> o��a �„� s���� <br /> City State Zip <br /> �j�"-�/�� <br /> Phone <br /> I understand m rights as stated a . <br /> s�' <br /> L� � <br /> Sign�t re <br /> ; <br /> F <br /> NG& ONING—473-7357 • ADMI�IISTRAT(ON&FINANCE—473-7358 <br /> • PUBLIC WORKS —�73-�359 <br /> BUILDI <br /> ASSESSING <br />