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.` � <br /> �_- ��Y� C��� o� ����TO <br /> Post Office Box 6&'Crystal Bay, Minnesota 5�323•Municipal O�ces <br /> ea s . <br /> � - <br /> On the North Shore of Lake�tinneton a <br /> • - • ' 0{ <br /> DATA PRSVACY ��SORY <br /> "Ri htS Oi subjec`S OL <br /> g <br /> -rn accordance with M.S. Z3.Oa , Subd•our request for a permit or <br /> -� � sae would I.ike to inforn you thof its departments nay require <br /> �.ata , o= prono or any <br /> I._cense from the City <br /> �. cer�ain rivate or coniidential insormat�on- <br /> vou �o s"urnish �` P <br /> you are noti�ied that: <br /> 1, The information you fui nor i��ensebrequest�d. aetermine your <br /> the e'--n-� <br /> cual_f'-cation for P <br /> 2. vou may reruse to supply <br /> data, but r�iusal may require that <br /> ,-•nit or Iicense. <br /> the City deny the pe_. , <br /> be snareci with other .Ioca1 , s�a�e or <br /> 3 . The information may o to process the pe'-�ni�. oi <br /> f ederal. agencies to the extent nec�ssary <br /> �icense. , <br /> Iice*�se requ�res Counc�I a��'-°r <br /> a, If your recuested pe�it or i <br /> to aporove, some in=or:na.tion �ay become pubyic. <br /> 5 . You have certain rignts under M.S. 13.04 to rev�ew Br=v��e <br /> data on yourself. <br /> 6 , your fu1l name is required to process this appZ�cation or <br /> pe*-lnit. <br /> C <br /> b � Last <br /> r^i st <br /> Middle <br /> �,� � �v - <br /> Address �— <br /> �� -S 3�3� <br /> State Zip <br /> City <br /> -�/' ,� � 767 � <br /> Phone <br /> I understand my rights as stated above. <br /> .��� � . <br /> � . <br /> � <br /> Signature <br /> �UILD�VG&ZONING—473-7357 • ADMIN1STFtATION&FINANCE—�i73-�358 <br /> • PUBLIC WORKS—4�3-�359 <br /> ASSESSIN G <br />