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. . <br /> j • - <br /> CITY o� ORONO <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 /> 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 wiZl 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 iocal , state or <br /> federal 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 Lo review pri�a�� <br /> data on yourself. <br /> 6. Your full name is required to process this applica�icn or <br /> permit. <br /> �l�'-� M+t j f'`� ��tiq-Z� �,���i t-, <br /> First Middle Last <br /> �;i�� ,i �\Y�c` •�11�� �� • <br /> Address <br /> �r o rv � r� S.� ��d P <br /> City State Zip <br /> ��.� — c, 4��.- � — <br /> Phone <br /> I understand my rights s sta ed a e. <br /> �1 <br /> Signat e <br /> �--�'"�� <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 � PUBLIC WORKS —473-7359 <br /> ASSESSING <br />