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r�t�' ,� <br /> .r.��. rr a;� .i� <br /> `'" a � , �t . <br /> � � ; <br /> K � � <br /> ° ��` a N� C ITY of �R��T� <br /> � � :t <br /> +s�,x��:.' � <br /> ;,.t.�. � ':��i <br /> �` , �-y.j�i i T� Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> 1 I:�,' � . �< '�t i <br /> � ' On the North Shore of Lake Minnetonka <br /> ���;',: �` a <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 /> 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 reques�ed. <br /> 2. You may refuse to suppl.y data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other iocal , s`ate or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requir�s Councii ac�ior. <br /> to approve, some information may become public. <br /> 5. You have certain rights under NI.S. 13.04 to review priva�e <br /> data on yourself. <br /> 6 . Your ful.I na:ne is required �o process this application or <br /> permit. <br /> � j _ <br /> u i�/'+r ��f �� /i �1..9!'- (� ,�v � (� �. �{��e: <br /> w <br /> Firsit Middle Last <br /> � '�(" ; � ali�- � i� � ��� l ,tl r <br /> �� <br /> Acidress <br /> � <br /> �' �,)� /L I'�/�i�-(i��� /�r►� �'; S � Y� -- <br /> City State �Zip <br /> (� � �� .� �;��J i .. "`�} �� e� ��' -%� <br /> Phone <br /> I understand my rights as stated above. <br /> , <br /> / j� <br /> , � , I J � �,4,.c��� <br /> Signa. ure <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION& FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />