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' �_-� <br /> . � / � � <br /> � <br /> ' O _ O N� <br /> -_-_ _ CI'�Y of ORO <br /> ,� ;:: ,� ;;;�.; �, .t,��� <br /> �.• �, .'�: .,` � Post o�ice sox 66 <br /> �,� . �,- . - :� � Crystal Bay,tilin►�esota 5�32"i-U066 <br /> lJ •,J.. ;,-.-``� <br /> �9kESII�4-. <br /> ��� <br /> DATA PRTVACY ADVISORY <br /> In accordance with �1.5. 13.04, Subdor license ifrom thee Ciryrot CO:ono o�an lo e i o <br /> inform you that your request tor a permit <br /> departments may require ��ou �o rurnish certain priva�e or confidential information. <br /> You are notified that: <br /> l. The information y�ou furnish will be used to determine ��our qualification for the <br /> permit or licensz requested. <br /> 2. You may refuse to supply data, but refusal may require that the City der.y the <br /> permit or license. <br /> 3. The information may be shared with other local, state or federal aaencies to the <br /> exter,t necessary to p:Jc�ss �il� permit or license. <br /> 4. If your requested permit or license requires Council accion to approve. some <br /> information mav becom� puolic. <br /> �, You have cerain ri�hts under M.S. 13.04 (see fo�lo�j�ina p�Q�) to review privare <br /> data on yourself. <br /> (. Your fu11 name is required to process this application or permit. <br /> PLEASE PRL�'T <br /> � �,�V�C1 �.�iWl i�L�.(.+�v�-- <br /> ���o �[Ya�CJ� <br /> First �fidd:e Last <br /> / yS"�/� 5-�-�` �'.� . <br /> Address <br /> 4vv✓ ,j-� 7 � <br /> ✓�S Phone <br /> Ciry State Zip <br /> I understand my riQhts as stated above. <br /> Si� ature <br /> T'EI.EPHO?YE-4T3-7357•FAX-4T3-O510 <br />