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03i�5i91 11:52 THE CITY OF G�ONO 612-473-?357 ��7 <br /> �• <br /> �I'T'��f (II�aN[� <br /> POet UffiCe �ox 68�Cryetal Day,Minnesota 6632$•Muriicipel Offioee <br /> • <br /> � � � �• On tJ�e North Shar'e of Laka Minnetonka <br /> DATA PRIVAC7f ADVISORY <br /> In BCCaZdAnGe with M.S. 13.04, subd. 2, "R�.ghts o� sub��ct� of <br /> data", w�s would �.�.ke to inform yau that your request fox a perm�� or <br /> �.icense fr�m the City o£ Qrono or ariy c�f its de��artments may require <br /> you to furnigh c�r�sin private os can:��.dent�.al infarmatian. <br /> Xou are z�o�if�.ed tha�s <br /> 1. Th� irifO�mation yoU �uxnish w�ii �e us�d �o determine your <br /> qualificat�.on tvt the permit oz liaense requested. <br /> 2. Xau may refuse Go supp�.y aatia, but refusa3. may requiar� �hat <br /> �he City deny the pexmi� or license. <br /> 3. The informat�.cn msy be shared with othex ].ocsX, state ar <br /> tedera3. ag�ncfes to the extent nece�sary to process the perma.t or <br /> Iicense. � <br /> 4. If your requested peririft ar I.ieense �requires Counci� actian <br /> to apprave, svme in�ormata,on may beaome public. <br /> 5. You have aertain rights under M.S. 13.04 tio review privat� <br /> data on yc�urself. <br /> 6. Your �u11 name is requ�.red ta process th�s application or <br /> perma.t. <br /> � � � �'! � � �;' " ' <br /> �First Middle Last / � <br /> � �.��i� •� - <br /> Address <br /> ��'�" ,�(.��_. 1-�l' -r�- -r'-�--�`�7_, <br /> Ci�y State Zip <br /> l��_ ' <br /> ��� ., <br /> Phone <br /> x understand my rights �s stated above. <br /> gnature . <br /> Bt1ILDING�ZONING�473•7357 • ADM[NISTRA7'!UN�c PITVANC�—473•T358 • PUUI.IC WORKS—4�3-7359 <br /> A55�SSING <br />