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'" ,-`--�- <br /> � � , <br /> "s".�,°� �' ' : <br /> '�,,a,�', ,c�,r. . <br /> �� �• ��� '� <br /> ��'������`�- CI'��' Of OI�ONO <br /> .���,�,?�RT'xr FI'Y <br /> +1.�-,a,"�b_"h�� '`T,�rrkh <br /> � - �.�i.ti i':_:?,'r <br /> ��".�%'° Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> ���: <br /> r:��:%'� <br /> � }�}� On the North Shore of Lake Minnetonka <br /> s - • a` . <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 from the ta n � r vate or conf dent al eP f rmationmay require <br /> you to furnish ce p <br /> You are notified that: <br /> l. The information you furnish wil.l be used to determine your <br /> qualification for the permit or license 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 local , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii ac�ior. <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�e <br /> data on yourself. <br /> 6 . Your full name is required to proc�ss this application or <br /> permit. <br /> �� � <br /> ��� f��,�� l�✓! L �Gti�%'J7 <br /> �O c.. � .J <br /> First <br /> Middle Last <br /> �s- �� � � l-�� ,�fZ <br /> Address <br /> � � / l � � <br /> f L,;��. ;„�- ll�' ���r�/ >> >3 <br /> City State ZiP <br /> ��/� D��J _ ��/`� <br /> Phone <br /> I understand my rights as stated above. <br /> , <br /> � ��� � � <br /> ignatur � <br /> BUILDING&ZONING—473-7357 <br /> • ADMINiSTRATION&FINANCE —�373-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />