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�_ - <br /> � <br /> . <br /> � �,� <br /> �M � <br /> ���� . <br /> =:� ��V� C�T�' o� O��l\TO <br /> ��: <br /> ._.�- .�-.��. <br /> .� <br /> � ` Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> i- <br /> f 0 <br /> ��`A _ � �; On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> In accordance with I�.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we would Iike to i�form you that your request for a permit or <br /> Iicense from the City of brono or any of its departments may require <br /> you to furnish certain pri;vate or confidential. information. <br /> You are notified tha�: <br /> 1. The information ; you furnish will be used to determine your <br /> qualification for th� permit or Iicense requested. <br /> 2. You may refuse 'o supply data, but refusal may require that <br /> the City deny the pe�it or license. <br /> I <br /> 3. The informatiorl may be snared with other local , s�ate or <br /> federal agencies to ;the extent necessary to process the permit or <br /> license. <br /> 4. If your requestled permit or license requires Councii ac��or. <br /> to approve, some in�ormation may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your full name� is required to process this application or <br /> permit. ; <br /> N'� l �N-� <br /> l_... ' � , ��-�2� � <br /> First Middle Last <br /> aa i � ���� �o� ,� T- ,�o �.� <br /> Address <br /> vvt�-i��9-T�- �vtn� �.�� � I <br /> City ^ State Zip <br /> y � � ��� .� <br /> Phone <br /> I understand my rig as stated above. <br /> Signature <br /> BUILDING& ZOtiiNG—473-7357 • AD'�i1NISTRATION& FINANCE—473-7353 • PUBL►C WORKS —473-7359 <br /> ASSESSIy G <br />