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�;.,.��,,ti <br /> � +'j�� -0-�s�� <br /> i �: � .��4 .W�N �i��� O� ����� <br /> 4F�- ,� , <br /> �'" �.'"t '�: Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> - �:,�. :.i <br /> :;�r k� ; :� <br /> '� `� �'# �''" ��� On the North Shore of Lake Minnetonka <br /> �-�►i- ;�. ;�: <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04 , Subd. 2, "Rights of subjects of <br /> data", we would 3ike 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 /> l. The information you furnish will 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 ar license. <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 Lo review prica�� <br /> data on yourself. <br /> 6. Your full name is required to process this applica�iaa or <br /> permit. <br /> _ �� <br /> ������-��y-, <br /> _ �a��, .�� .��,� <br /> i ,'j�''��U�n,, ' � <br /> ''�� ', �i� � -�C <br /> ,V�_'. '✓,-, <br /> First Middle Last <br /> � �, <br /> - ����-;�.��'I�� ����� <br /> Address <br /> 1;'ti�,t�Z�;C��l I"��if� �_;,;_ I <br /> City State Zip <br /> ���� .�'� �,�� <br /> Phone <br /> I underst d my ri hts as stated above. <br /> _,_- _ � <br /> � _�-, 1, - <br /> � j' � -- l � ����'(l.�t,�� <br /> S�1g�a�ure� � Y <br /> BUILDING&ZONING-473-7357 � ADML�IISTRAT[ON&F[tiANCE -473-7358 • PUBLIC WORKS -473-7359 <br /> ASSESSING <br />