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. � <br /> � <br /> CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minneaota 55323•Municipal Officea <br /> � <br /> • - � • On the North Shore of Lake Minnetonka <br /> DATA PRNACY 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 /> 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 /> 1. 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 license. <br /> 3. The information may be shared with other local, state or <br /> federal. agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or license requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�� <br /> data on yourself. <br /> 6. Your full name is required to process this applicatian or <br /> permit. <br /> �i c i-�tti�7 ��� � �i T"T'C_� <br /> First Middle Last <br /> �8 g0 S f�f�`Dy��4o� ��, <br /> Address <br /> �.e�4�z,q-� �'1 n� 5"s3 q � <br /> City State Zip <br /> ( (,} ��� �-1-�1 ( -�87 S` <br /> Phone <br /> I understand my rights as stated above. <br /> / }� ` <br /> .� r� <br /> Signature <br /> BUILDING 8c ZONING—473-7357 • ADMINISTRATION 8c FINANCE—473-7358 • PUBL[C WORKS—473-7359 <br /> ASSESSING <br />