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. � <br /> � OIiONO <br /> CITY of <br /> Post Office Box 66•Crystal Bay, Minnesota 55323•MuniciP� ��� <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 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 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 oth�ocesscthe permit or <br /> federal agencies to the extent necessary to p <br /> license. <br /> 4. If your requested permit or license requires Council ac��or. <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6 , Your full name is required to process this application or <br /> pe?�mit. <br /> �io��K <br /> �� � � Last <br /> First Middle <br /> p� ^I ( � <br /> � 0 `�� �V� � (,l� )Ci �C_�'x - <br /> Address <br /> ,/� � -� <br /> �G� � I ►I� -J�� <br /> City State Zip <br /> �-t7i - Iu � � <br /> Phone <br /> I understand my rights as stated above. <br /> ' <br /> �____ <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 <br /> • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />