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� , •.-�` <br /> <� <br /> �.. .' <br /> S� � ����� <br /> ��- CI'�I' o <br /> a zW� <br /> ��._ <br /> l .�� <br /> r' <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> � <br /> � _ � � On the North Shore of Lake Minnetonka <br /> DATA PRIVACY 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 /> license from the City o r � ate or conf dent al e nf rmationmay require <br /> y o u t o f u r n i s h c e r t a i n p <br /> You are notified that: <br /> l. The information you furnish will be used to determine your <br /> qualification for the permit or Iicense requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be snared with other local , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or I.icense 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 full name is required �o proc�ss this application or <br /> permit. <br /> �� � <br /> i' �-- � �i A � �:�� ��i���� <br /> �_7 � �; �, , , <br /> � Middle Last <br /> First <br /> � � �-. /'�` -=> ,f;,� �� ,�; ;r . <br /> ✓ <br /> Address <br /> - ^ ',, i <br /> (�J �� j "� �l- ; �1 /1'1 /� � _ , ; <br /> City State Zip <br /> _ , .r - - <br /> _� ' �:_. - � <br /> Phone <br /> I understand my rights as stated above. <br /> '-� ,,? �-,� �� � - <br /> �-� � �� �� _.�-"- <br /> Signature — <br /> BUILDING&ZONING—473-7357 <br /> • ADMINISTRATION&FINANCE—�173-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSIN G <br />