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• � " <br /> � <br /> CITY of ORONO <br /> ' Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> � . � � 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 /> Iicense 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 /> I.. The information you furnish wi1.1 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 Counci3. action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�� <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> � <br /> '�,Q,��y`�.. l�.JC���':� �..c C� .`.� <br /> First ,,., Middle t <br /> t�v / \ 4'�`\f"";,� 'C �'�,,```^ `� `�`y`�--�'�,�t„Q-' <br /> Address <br /> ��{���..��..C..� ������ �� ��� <br /> City State Zlp <br /> �l a-����,� �� <br /> Phone <br /> I underst/ nd y rights as stated above. <br /> �' <br /> ��r <br /> Signature � � <br /> BUILDING&ZONING-473-7357 • ADMINtSTRATION&FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING ' <br />