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� <br /> u <br /> � � ���'� o� O��I�TO <br /> « . . post Office Box 66•Crystal Bay.Minnesota 5�323•Municzpal Offices <br /> f <br /> On the North Shore oj Lake Minneto a _ <br /> • - • � <br /> DAT�1 PRIVI�CY ADVISORY <br /> . that our request for a permit or <br /> In accordance with M.S. 13.O�u. Sub� 2, "Rights of subjects �e <br /> data", we would like to inform y o f its departments may requi <br /> licease from the City of Orono or any <br /> �ou 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 or license. <br /> 3. The information may be snared withto processcthe permit or <br /> federal. agencies to the extent necessary <br /> ?icense. <br /> q, If your requested pe*�it or license requ�res Councii ac�ion <br /> to aporove, some information may <br /> become public. <br /> �. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6, your full name is required to proc�ss this appl.ication or <br /> pe*-mit. <br /> � ���� <br /> ��,�.�s �'`� �- <br /> Middle Last <br /> First � <br /> 2oS�0 <br /> Address � ,�� � <br /> i-�. - � 5 <br /> City <br /> State Zip <br /> �(�1 l — ��c=z� . . <br /> Phone <br /> ri hts as ed ove. <br /> I understand my 9 , <br /> Si atu <br /> � • PUBLIC WORKS—473-7359 <br /> BUILDING&ZONING—473•7357 • ADMINISTRATION&FINANCE—473-7358 <br /> pSSESSING <br />