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� <br /> F- � <br /> � � � ��'��.' o� ���I�TO <br />� Post Office Box 66•CrYstal Bay,Mi.nnesota 5a323•Municipal Offices <br />� a� ' <br /> s - <br /> On the North Shore of Lake Minnetonka <br /> • - • • <br /> i DATA PRIVAC�' A��SORY <br /> Subd. 2, "Rights of subjects of <br /> In accordance with M.S. 13•ou'that your reguest for a permit or <br /> I' we would like to inform Y o f its departments may require <br /> data" , of Orono or any � n=o�ation. <br /> �i.cense from the City rivate or confidentia1 <br /> you to furnish certain p <br /> You are notified that: <br /> �. The inrormation you furnish wil.l be used to determine your <br /> qualificatioz for the pe=�1� o= license requested. <br /> 2. You may refuse to supply <br /> data, but refusa3 may require that <br /> tne City deny the permit or license. <br /> be snared with other local , s�ate or <br /> 3 . The information may rocess the permit oi <br /> f ederal agencies to the extent necessary to p <br /> �icense. • <br /> a, ;i your requested permit or <br /> license requlrPs Council ac��or. <br /> to aporove, some inrormation may <br /> bec�me public. <br /> You have certain rights under M.S. 13.04 to rev�ew priva�e <br /> data on yourself. <br /> 6 . Your full <br /> name is recuired to proc�ss t^is applicat'on or <br /> pe�it. <br /> � ti� <br /> � �,� ast <br /> Middle <br /> r^irst , <br /> ,� �� �� <br /> Address �,� � <br /> .- �� � �-> <br /> �`'`� ��� S ate Zip <br /> City <br /> t 1.� � ,�-��-� CG- <br /> Phone <br /> I understand my rights as stated above. <br /> r � . <br />. �'t \ . • . <br /> Signature <br /> � pDMINISTRA'tiON&FINANCE—;73-7358 <br /> • PUBLIC WORKS—473-7359 <br /> BUILD[NG&ZONING—4�3-i 357 <br /> ASSESSING <br />