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� � <br /> � � (����' o� ��►�IiTO <br /> M <br /> Post Office Box 66•Crystal Bay,Minnesota 5�323•Municipal Offices <br /> ! _ <br /> On the North Shore oj Lake Minneto a <br /> • ' • • <br /> DATA PRSVACY AD�SORY <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 of its departments may requ1 <br /> license from the City oi Orono or any <br /> you to furnish certain private or confidential inzormation. <br /> You are notified that: <br /> l, The information you furnish will be used to determine your <br /> aualification for the permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> tne City deny the permit or license. <br /> 3, The inf ormation may be snared Withto proc sscthe permit or <br /> f ederal agencies to the extent necessary <br /> license. <br /> q. If yvur requested permit or Iicense requires Councii ac�'or <br /> to approve, some information maY <br /> become public. <br /> �, 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 proc�ss this application or <br /> pe=znit. <br /> Yv � <br /> �C e � Last <br /> Firs� Mid le <br /> � L(„1�. Y ' <br /> Address � �`�/ � <br /> � v1 <br /> City <br /> � � State' Zip <br /> ��� - 3�� � <br /> Phone <br /> r' hts s ted above. <br /> I understand my . <br /> Signatur � <br /> � • PUBLIC WORiGS-473 7359 <br /> SUILD[NG&ZONING-473-7357 • ADMINISTRATION&FiNANCE-473-7358 <br /> ASSESSING <br />