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'� s . <br /> � � ���� �� ����� <br /> Post Office Box 66•Crystal Bay,Minaesota 5a323•Municipal Offices <br /> FI! � <br /> � Orz the North Shore of Lake Minnetonku - <br /> • - •l + • <br /> DATA PRSP�� ��SORY <br /> 13.0� , Subd. 2, "Rights af subjects of <br /> with M.S• ou that your request for a permit or <br /> In accordance require <br /> we would like to inform y of its departments may <br /> data", o= Orono or anY <br /> license from the City rivate or con=;dential insormation. <br /> you to furnish certain p <br /> �,ou a+e notified that: <br /> mhe information you furnisii ensebrequested, Qetermine your <br /> 1. eT-nit o� <br /> qualification for the p � requiro �hat <br /> refuse to supnly data, but refusa_ may <br /> 2. You may the permit or license. <br /> tne City deny ar local , s�a�e or <br /> 3 . mhe information may be snared wYth �throcoss the permiL °1 <br /> f edera� agencies to the extent necessa�y to P <br /> �icense. , ac��or_ <br /> �, �i yaur recuest=a pe='n1t <br /> or Iicense requyres Councis <br /> ; ation may become public. <br /> some nf orm <br /> `o �porove. • ; vate <br /> � , you have certain rights under M.S. 13.04 to re�"-eW �r` <br /> data on yourself. • or <br /> 6 _ Your ful.l name is required to proc=ss this apnZ�C3`=-On <br /> pe�it. <br /> , � � � � � <br /> � �.�-��rv�'c J <br /> _....� \ <br /> �> . t� LzS�. <br /> First <br /> Middle <br /> ��� <br /> �Cv��� � , .� �� <br /> Address <br /> � `_S3�' <br /> ' �� i� Z ip <br /> � r'' State <br /> Ci�y <br /> �I � � - �1�5y <br /> Phone <br /> I understand my rights as stated above. <br /> < �� _ <br /> � <br /> � � ��-- -- . <br /> Signature <br /> BUILD[NG&ZON[NG—473-7357 • ADhtINISTRATION&FINANCE—�73-7358 <br /> � PUBLIC WORKS —473-7359 <br /> p5$ESSING <br />