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or license? Include permit or license number. <br />( /cv) LL (-4 (6 2: ice Se L lll �_'� / <br />I understand that the information provided in this application may be considered private or <br />confidential data. I further understand that I may not be required by law to provide such information. <br />The purpose of providing such information is to aid the City of Little Canada in its determination on <br />niy application for a permit. I acknowledge the providing, or failing to provide, such information <br />may affect the City's determination on my application. I understand this information will be made <br />available to the City of Little Canada, its City Council, agents and representatives, as well as the <br />Minnesota Department of Revenue, or any other person or entity authorized by law to receive said <br />information. I release the City of Little Canada from any and all liability for its receipt and use of <br />data received pursuant to this application. <br />STATE OF MINNESOTA ) <br />COUNTY OF (,, < `! ) <br />being fast duly sworn, upon his /her oath, <br />deposes and says that he /she is the person who has executed the above application, and that the <br />statements made therein are true of his /her own knowledge and belief <br />/L /. X4%0? -1 <br />signature C T �! <br />Title <br />Subscribed and sworn to before me this <br />day of <br />BRIAN S BAUER <br />NOTARY MJEUC • MINNESOTA <br />MY Cpl C RE81,3112013 <br />8 <br />7 <br />20/ <br />Notary Public <br />L <br />County <br />My commission expires_ <br />?o( <br />