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�� <br /> � � <br /> o = - O �� <br /> C�'T�' Of �RO <br /> �, : ' �;:'��•- � �t�,�ot�� <br /> ,� �_ ti P�o�soX� <br /> �'C� , ^ ;l '`: �J~ Crystal Bay,�t;nnesota 5�32�0066 <br /> �`�kESH��� <br /> DATa PRIVACY ADVISORY <br /> In accordance «�irh `i.S. 13.0=�, Subd. ?. "Rivhts of subjects oT data". we would lil:e to <br /> intorm ��ou that your request ror a p�rmit or license rrom the Ciry oi O:ono or any oi its <br /> departments may require ��ou to furnisn cenain pri��a�e or contidential information. <br /> You are notiiied that: <br /> l. The inforrriation ��ou fi,�raisn will be used to determine }�our qualification for the <br /> permit or licensz requested. <br /> ?. You may refuse to suppl}� data, but refusal may require *�hat the City der.y tr�e <br /> pernit or �icense. <br /> ;, The information may be snared «�ith other local, state or federal aaencies to t}.e <br /> eYtcr�t .lecessary to pro�ess «�� Perr7it or license. <br /> 1. If ��our requested permic or license requires Council action to approve. some <br /> inrormation mav becom� DllDl1C. <br /> �. You ha��e ce;.ain ri�rts und;.r M.S. 13.0^ (see follo���in, paQP) to revie�v private <br /> data on yourselt. <br /> 6. Your full name is required to process this applica�ion or permit. <br /> PLEA�E PRL�T <br /> �' �-`� �%��/ f�� <br /> First �f idd;e Last <br /> r— <br /> ����-1 �� ����x� � C 1 <br /> .�ddress �, <br /> G�-�r�?��l 1�1 V'`�11� �.�� :� <br /> C ity <br /> State Zip rhonc <br /> I understand my riahts as sta�ed above. <br /> �, --- <br /> SiQnarure <br /> v TEI.EPHO�V�E-373-7357• F.�?C-�73-0510 <br />