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� � � _ <br /> �,: c��_�,,- <br /> �.� � �- <br /> ��' �'�`' `� ` <br /> � �,�. � <br /> , ���., �f�F � �i��� �� ����� <br /> �:�--�, ;� r :,� <br /> '�::�w.�;.�.�,��:� <br /> - ����� �l;:a;. <br /> ''�• Post Office Box 66•Crystal Bay,Minneaota 55323•Municipal Officea <br /> �3a <br /> =::�r�:-;tx <br /> s - � .� On the North Shore of Lake Minnetonka <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 /> license from the City of Orono or any of its departments may require <br /> you to furnish certain private or confidential information. <br /> You are 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 license. <br /> 3. The information may be shared with other iocal , state or <br /> federal. agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or license requires Counci3. action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�e <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> /l'/�h�:,��j-� /�' r�/��c,it'�� <br /> First Middle 'Last . <br /> �- �7�� /l, fi�/�✓ f ;✓ �,(� <br /> Address <br /> o� ���� m�% .�s3 '� s <br /> City State Zip <br /> �' ��: - o �- � -� <br /> Phone <br /> I understand my rights as stated above. <br /> � <br /> ���`.�r� ,�E • .�;%° ,�, ;�^/ . <br /> ignature <br /> BUILDING&ZON[NG—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />