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��+� ��.!a,4� ��.J <br /> +^ ��,x ;� ,.7 <br /> �gA."aY�� r3lt <br /> � � a - ' � - CI'�1' Of O�b��T� <br /> '�.,, n�� r` � <br /> ��!^� Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> x�''•' <br /> ��aa�a � <br /> Y`���"��- � � 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 /> l. 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 public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�ate <br /> data on yourself. <br /> 6. Your full name is required to process this applicatian or <br /> permit. <br /> George R. Bloarn & Theresa A. Bloor�l <br /> First Middle Last <br /> �7d RPC'F Pni nt TZndr� <br /> Address <br /> -Pr r�iJ ���F4 <br /> City State Zip <br /> 472-�y�6 <br /> Phone <br /> I understand my rights as stated above. <br /> � 7 1 _ � �: <br /> � ,< �i" ��}'- '14�,1 <br /> ��.�1 ���� L "� G� � <br /> Signa ure <br /> BUILDING&ZONING-473-7357 • ADMINISTRATIOIY&FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />