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♦ <br /> . <br /> � � (��[��" o� ���NO <br /> Post Office Box 66•CrYstal Bay,Mirsaesota 5a3�•M"�ap��� <br /> � On the North Shore of Lake Minnetorcka - <br /> • ' • � <br /> DATA PRSVACY A��TISORY <br /> at our request for a permit or <br /> Sa accordance with M.S. 13.Ou`thub y 2' "Rights of subjects �e <br /> data", we would like to inform Y° of its departments may requi <br /> license from the City of Orono or any <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> 1, The information you furnish will be uuested, aetermine your <br /> qualification for the per•nit or license req <br /> � 1 data, but refusal may require that <br /> 2. You may refuse to supp Y <br /> the City deny the permit or license. <br /> 3. The information may be snared with oth=Ce scthe permit or <br /> f ede=al agencies to the extent necessary to p <br /> license. <br /> our requested permit or I.icense rern�yres Councii ac��o% <br /> a, If y become public. <br /> to approve, some information may <br /> �. You have certain rights under M.S. 13.04 to review priva�e <br /> data on yourself. <br /> 6, your full name is required to procsss this application or <br /> pe�-;nit. <br /> � � <br /> e"� Middle Last <br /> First <br /> 0�1 �-�o � � c�,�--c— — <br /> Andress <br /> ma�I�� a t w Z1P— <br /> ity <br /> State <br /> '`� 7 / - 0 .38:� - � 7/ -oso7 <br /> Phone <br /> I understand my rights as state,d above- <br />� <br />€ � �_ . <br />, � . <br /> S gnature � <br /> BUILD[NG&ZONING-473-7357 • ADMINISTRATION&FiN.�NCE-�73-7358 <br /> • PUBLIC WORKS-473 7359 <br /> ASSE3SING <br />