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. <br /> .,�,a <br /> �.�_ � �m �`�' o� �ROIeTO <br /> x ,. �I <br /> z�t <br /> :�.: �-����. <br /> _ ;.�.�w <br /> Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> 0 <br /> • - • s r On th.e North Shore of Lake Minnetonka <br /> DATA PRNACY AD�S ORY <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 /> license from the City �f �ate or conf dent al e nf rmationmay require <br /> you to furnish certain pr <br /> You are notified that: <br /> l. The information you furnish will be used to determine your <br /> qualification for the permit or Iicense 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 oth�ocesscthe permit or <br /> federal agencies to the extent necessary to p <br /> I.icense. <br /> 4. If your requested permit or Iicense requires Councii. a��'or <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6, Your full name is required to process this application or <br /> permit. <br /> � C� � � <br /> First <br /> Middle Last <br /> I �5 �.��" Co� a� <br /> Address � �S�c/ � � <br /> ��l�'ls%�.�`� � � <br /> City State Zip <br /> �-�3 -- �3 � 7 <br /> Phone <br /> I u stand my rights as st e above. <br /> � <br /> Signa ure � <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 <br /> • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />