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1 <br /> f <br /> _ � � �r��� �� ����� <br /> I �.1� <br /> . Post Office Box 6b•Crystal Bay, MinIIesota 5a��•M�ap��� <br /> li � _ <br /> Orz the North Shore of Lake Minnetorc a <br />, � - • • <br /> DATA PRI�ACY A1��SORY <br /> n accordance with M.S. 13.04 , Subd. 2, "Rights of subjects of <br /> I our re uest for a permit or <br /> we would Iike to inf orm you th o f its departments maY requ1re <br /> data", o= Orono or any <br /> license from the City r;vate or confidential information. <br /> you to furnish cer�ain p <br /> �ou are notified that: r <br /> 1, The information you furnish wil.l bee�uea�ed, aetermine you_ <br /> cualification for the per:nit or license <br /> 2. You may refuse to supply <br /> data, but refusal may require that <br /> tne City deny the permit or license. <br /> be snared with other local , s�a�e or <br /> 3 . The information may to process the pe�it or <br /> f ederal agencies to the extent necessary <br /> �icense. . <br /> �o� Pe,-;nit or Iice*�se requlres Counci� ac��or_ <br /> a. ;f your reques�� become public. <br /> `o �pprove, some <br /> �n=ormation may <br /> � . <br /> You have ce=tain rights under M.S. 13.04 to rev�ew priva�e <br /> data on yourself. <br /> � ,-ocess this 3T7L7Iicat�on or <br /> 6 , Your fu11 name is required �o P- <br /> pe�it. <br /> � ��� <br /> ��...1�-- <br /> Z,d s i. <br /> First <br /> Middle <br /> � �7�1 c.�-�v,r��� 12� <br /> Address <br /> U..Lf-.l �j.��`�� <br /> v�T��"A Z 1D <br /> State <br /> City <br /> ��8- <<� � � <br /> Phone <br /> I understand my rights as stated above. <br /> � . <br /> Signature <br /> BUILD[YC&ZONiNG—473-7357 • ADMINISTRATION&FiNANCE--�73-7358 <br /> • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />