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��-�"�.� � ''� . <br /> �}„��"r � <br /> q-.m.- 44� f? ' _ <br /> �-���� � �� � C+I'�I' O� O1��IIeTC� <br /> �-�,�-�-�tg �;: <br /> *4�'r> ��' <br /> � ,�.er' w s:;��' �c <br /> -��I�'�`-s .,;3 Post Office Box 66•Crystal Bay,hlinnesota 55323•Municipal Offices <br /> � �� �� 1 �y� <br /> �-�3 <br /> `1�����t ' � On Ehe Nortiz Shore of Lake Minnetonka <br /> ,. � � �,°: <br /> DATA PRNACY ADVISORY <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 /> Iicense fromri ce tain � r '��vate or conf dent aI e nf rmationmay require <br /> you to furnis P <br /> You ar.e notified that: <br /> 1. The information you furnish will be used to determine your <br /> qualification for the permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with other Iocal , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii ac��o% <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 ful.I name is required to proc�ss this application or <br /> permit. <br /> `��� t t����"�`'� <br /> First <br /> Middle Last <br /> (y-�--{-�� �.����r -�,� �-�-�=�i� <br /> Address <br /> �;�.,�.�..� ,,� �? �5'-�.��f- - <br /> �' State Z1p <br /> City <br /> ���r- �.1.5 �c:`� <br /> Phone <br /> I understand my rights as stated above. <br /> � ��,-----S-s�- <br /> S gnature . <br /> BUILDING&ZONING— 473-7357 <br /> • ADMINISTRATION&F(NANCE—�173-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />