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. • . '� � <br /> � � ����' o� ����TO <br /> Post Office Box 66•Crystal Bay,Minnesota 5a323•Munidpal Offices <br /> M! <br /> � - <br /> On. the North Shore oj Lake Minrzetonka <br /> • ' • • <br /> DATA PRNAC�' ��SORY <br /> Subd. 2, "Rights of subjects of <br /> In accordance with M.S. 13•ou`that your request for a permit or <br /> we would like to inform y o f its departments may require <br /> data" , o= Orono or any <br /> license from the City rivate or coniidential in=ormation. <br /> you to furnish certain p <br /> you are notified that: <br /> 1, The information you furnish wil.I- be used to determine your <br /> aualification for the pe=�=� oi Iicense requested. <br /> 2. You may refuse to Sl1UDI-Y <br /> data, but refusal may require that <br /> t:�e City deny the permit or license. <br /> be snared with other local , s�ate or <br /> 3 . The information may rocess the permi� oi <br /> f ederaZ agencies to the extent necessary to p <br /> license. . • <br /> a. I� your recuested permit or <br /> Iicense requ�res Counc�s a�='-°r <br /> to approve, some insormation may <br /> become public. <br /> J • <br /> You have certain rights under M.S. 13. Oa to rev=ew priv��e <br /> data on yourself. _ <br /> ; to rocsss this appl�cat�on or <br /> 6 . Your ful.I name is reau_red P- <br /> pe�it. <br /> �LS�� <br /> uJ2 � Last <br /> First Middle <br /> :�2 S1`� �1 � 5 - <br /> �� i �D�1-� <br /> Address <br /> L � � ,v ! Z1.D <br /> State <br /> City <br /> �� %� �� �� <br /> Phone <br /> I understand my rights as stated above. <br /> � � . <br /> � � ��� <br /> r <br /> � � ' <br /> S1 ure <br /> BUILD[NC&ZONING-473-7357 • ADMINISTRATION&FINANCE-473-7358 <br /> • PUBLIC WORKS -473-7359 <br /> ASSESSING <br />