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� . , <br /> �,-,�. ��'t > <br /> 4�z <br /> a�.,~A".r y ft �i,t�+�•�;� <br /> �y-�;,y✓'�,. ��,��i,,;�= <br /> �� ��`��' �"'f'= � Ci��� O� ���N� <br /> �� <br /> r»�,a :y ��,";�.� '. <br /> �: <br /> . � . �.'::Aaike-::�:� <br /> '�^,T�.'1:-', <br /> �„> 4� .�-.. Post Office Box 66•Crystal BaY.Minnesota 5a323•Municipal Offices <br /> ,� <br /> :�ri:.-;+ _ <br /> , ^ " .'_� <br /> � _ v �-;. 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 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 Iicense 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 /> 4. If your requested permit or Iicense requires Councii. action <br /> to approve, some information may become publ.ic. <br /> 5, You have certain rights under M.S. 13.04 to review pri�ate <br /> data on yourself. <br /> 6, yaur full name is required to process this applicatioa or <br /> permit. <br /> � c��,��- ��, � ���- <br /> �.���- �,�. <br /> First ('1�iddle La <br /> ` ' � <br /> l�� � ��� �C� ��� ��.v�. <br /> Address �� r2 �� <br /> ��� ���� � � <br /> City State Zip <br /> �1 a "� � � � <br /> Phone <br /> I underst d my rights as stated above. <br /> Signat re <br /> , <br /> BUILD(NG&ZONING-473-7357 • ADMINISTRATION&FINANCE-�73-7358 <br /> • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />