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r - '—� <br /> � � ' V <br /> O ..- : o ��� <br /> C���.' o� �R <br /> ,� � i ;�:- _ >., .i�s�o�� <br /> r�' <br /> . �� Ey Post ot�ce Box 66 <br /> `'�,� . , �ti. ' :�, �'1' Crystal Bay,`liruiesota 5��2�0066 <br /> . j., , <br /> ��kESH�4� <br /> .;�__- <br /> DAT� PRIVaCY ADVIS4RY <br /> In accordance «'ith `i.S. 13.0=�. Suod. ?, "RiUhcs of suojec:s o�� data". �ve would lil:e to <br /> inform `�ou that your request ror a p�:r.iit or Iicense irom the Ciry oi O:ono or any of i�s <br /> departments may require �rou to �urnisn c�rtain pri��a�e or confidential inrormation. <br /> You are notified that: <br /> 1. The infoznatior. ��eu n�rni�n ��'ili be used to determine ;�our qualification for the <br /> permit or license requested. <br /> ?. �'ou may refuse to suopl�� daca, but refusal may require *�hat the Ciry der.y the <br /> pernit ar license. <br /> 3. The infornation may be shared «�ith other local, scate or iederal aaencies to t?:e <br /> extent .lecessar}' CO Drocess :.�� Pe:Mit or licer.se. <br /> s, If ��our requested pernit or license requires Council accion to approve. some <br /> intormation ma�� becam� ouoiic. <br /> �, You ha��e ce�ain ri�rts und�r �i1.S. 13.0^ lsee fe�lo���in� p3Q�) to review private <br /> data on �ourself. <br /> (. Your full name is required to process this application or permit. <br /> PLE�SE PRL�'T <br /> �' j� �P��e U �✓I <br /> I C? IM { La <br /> F1LSt �'11QQiL <br /> 1 g�`6�A- rv1�i k.�- �� t� � <br /> .�ddress <br /> ,. �G�� � �v��`� 3�( �f75- ��� �? <br /> C i�� <br /> State Zip Phone <br /> I understand my ri�hts as scaced above. <br /> � <br /> �/'�/ ? � �rm1�a��z�,-C_ <br /> Sianatur� <br /> V TELEPHON�-�i73-73��� FAX-J73-0�10 <br />