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4- � <br /> ` RONO <br /> CITY of O <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 3ike 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 /> 1. The information you f t or li ensebreque tea, determine your <br /> qualification for the perm <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 , s�ate or <br /> federaI. 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 to review priva�e <br /> data on yourself. <br /> 6. Your full name is required to procsss this application or <br /> permit. <br /> First <br /> Middle Last <br /> Address <br /> City State Zip <br /> Phone <br /> I understand my rights as stated above. <br /> Signature � � <br /> BUILDiNG&ZONING—473-7357 <br /> • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />