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' � � <br /> ' � (����' o� ���I�T� <br /> - Post Office Box 66•CrYstal Bay,Minae�ota Sa323•Muaicipal Offices <br /> M! <br /> ° On the North Shore of Lake Minnetonka - <br /> � - o s <br /> DATA PRI�� ��S�RY <br /> 13.04 , Subd. 2, "Rights of subjects of <br /> with M.S. our request for a permit or <br /> In accordance } require <br /> �ata", we would I.ike to inform you th o f its depar`ments may <br /> license from the CitY o= Or°no or any <br /> yo <br /> u to furnish certain private or conri dential insormation. <br /> vou are notified that: <br /> e information you f urnish censebrequested_ aetermine your <br /> �, Th e,-mit ar li <br /> qualit=cation for the p uire that <br /> refuse to supply data, but refusal may req <br /> 2, You may the permi� or license. <br /> the City deny <br /> be snared w�th other local , s�ate or <br /> 3 . The information may <br /> to process the permit oi <br /> federai agencies to the extent necessary <br /> license. , ac��o% <br /> or iice*�se reaulres Councis <br /> d. I= your requested pe'-�it ublic. <br /> `o zDprove, some insormation ma_v become p <br /> � . Yo <br /> u have certain rights under M.S_ 13.04 to rev'-ew pr1V�`e <br /> data on yourself. � ; or <br /> Your full name is required to proc=ss <br /> this applica�_on <br /> 6 . <br /> per;nit. <br /> ��� ��Gc�(�- <br /> � <br /> ` Las� <br /> �i,-st <br /> Middle <br /> C ( �L S �1 � S� ' ( �� � <br /> Address <br /> �,�, 1.i . S � �� � � <br /> �� -1 7 F- Z 1D <br /> �`L" S`3tC <br /> C�tV <br /> � 3s� - s�a , � � <br /> Phone <br /> I understand mY rights as stated above. <br />�9 � -� � <br /> � '�-�,L�� ��1��.� . . . <br /> Signatu <br /> BUILD[NG&ZO`rING-473-7357 • ADMINISTRATION&FiNANCE-473-7358 <br /> � PUBLIC WORKS -473-7359 <br /> qSSESSIN G <br />