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' ' �' ' <br /> � <br /> C ITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minneeota 55323•Municipal Officea <br /> • <br /> � - � a 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 like to inform you that your request for a permit or <br /> Iictense 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 /> l. The information you furnish wi3.I 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 Iicense. <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 /> I' 4. If your requested permit or 3.icense requires Counci3. action <br /> to approve, some information may become public. <br /> 5. You have certa;in rights under M.S. 13.04 to review pri�a�� <br /> data on yourself. <br /> 6. Your full name is required to process this appl.ication or <br /> permit. <br /> M r�aP[� f� , �����-f�l-�/Z 1� <br /> First Middle Last <br /> Z l7 7 c�-�c7�V�9�1C�c� 2t� <br /> Address <br /> 1�J-�`�Z�►Ti� I`1 i� �S'J��� <br /> City State Zip <br /> �( 7l -7DC�� <br /> Phone <br /> I understand my rig,hts as stated above. <br /> �j 2.� <br /> Signature <br /> BUILDING&ZOIYING—473-7357 • ADMINISTRATION&.FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />