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x <br /> �� �'� ;�iv"�°'.t <br /> �1.ir�. �' �h �� N�. <br /> 4� � 4- <br /> �R F• <br /> �� ,�- _� (��'�'�" �� 0�O1�T� <br /> r ,� . ,,. <br /> _;� r� s ,,a z: <br /> .cr�.� �:F-� <br /> :yu3� _::�:, � � `:: <br /> ,,_�� . �: Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> ��M1; �� _� _ <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 /> l. 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 Ioca3, s�ate 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 actior_ <br /> to approve, some information may become pub3.ic. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6 . Your full name is required to process this application or <br /> pe�-mit. <br /> l�enn�� G nvh.� <br /> First Middl.e Last <br /> 6/5 C.Larcence {lve <br /> Address <br /> l�vund lt]��f SS36/� <br /> City State Zip <br /> /��2-29�/ <br /> Phone , <br /> I u derstand my rights as s e above. <br /> � <br /> / r /"f � <br /> -Y <br /> Signature � <br /> BUILDING&ZONING-473-7357 • ADMINISTRATION&FINANCE-�73-7358 • PUBLIC WORKS-473-73�9 <br /> ASSESSING <br />