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, • ti <br /> � f�rn;�, J\ . "R'°��:� <br /> � �,wYn�d IJ`s ��. a� <br /> � , CITY of ORONO <br /> ���, � . <br /> _���� ���, . <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 /> l.icense 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 /> qual.ification 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 license. <br /> 3. The information may be shared with other iocal , state or <br /> federal agencies to the extent necessary to grocess 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 ander M.S. 13.04 to review pri�at� <br /> data on yourself. <br /> 6. Yaur full name is required to process this apF,I.ication or <br /> permit. <br /> ,� � �,�� � <br /> irst Mi e Last <br /> � `(� �,,'���f7'1'�f �J i,+C.�'� /'�V <br /> Address �— <br /> ��/ ����� <br /> //�<��,� �l% <br /> Cit� State Z1p <br /> '' � =� <br /> 1�//--�T �� _ <br /> --� - <br /> Phone <br /> I understand my rights as stated above. <br /> �� _ _✓/ ��. <br /> /%,- -y� -.� � <br /> Si nature � � <br /> BUILDING&ZONING—473-7357 � ADMINISTRATION&FINA[VCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSFSSING <br />