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i . <br /> 4 '� <br /> T.��{��. ��yt � <br /> ��y � � •��5���+ �� <br /> r� , �: :� G I'�Y O� O�O <br /> ;�`r } ti,r,��TM^��`�'�:, - <br /> �„�»� ��, ��� � <br /> �`�"�- W� `-�.�, Post Office Box 66•Crystal Bay,Minnesota Sa323•Municipal Offices <br /> -.�„a. "�. <br /> u�. ! �. <br /> : -� _ o �•. On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> ��In accordance with M.S. 13.04 , Subd. 2, "Rights of subjects of <br /> data , we would Iike to inform you that your request for a permit or <br /> Iicense fromri certa n pr vate or onf dent a 1 i formationmay require <br /> you to furnis <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your <br /> qualification for the permit or Iicense requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other iocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> 3icense. <br /> 4. If your requested 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 yourself. <br /> 6. Yaur full name is required to process this applicatian or <br /> permit. <br /> 132,� �4 L,�-,� Pa fl�,�—z_- <br /> First Middle Last <br /> ���7 � l��'�'''^�r�� ��� <br /> Address <br /> ,�,.1 �� �'� `5-S`�6 y _ <br /> City State Zip <br /> ��� :�-- :,;� /1 <br /> Phone <br /> I understand my rights as stated above. <br /> �� ..._ <br /> Si n fure <br /> BUILDING&ZONiNG—473-7357 • ADMINISTRAT'ION&FINANCE—473-7358 <br /> • PUBLIC wORKS—473-7359 <br /> ASSESSING <br />