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t � <br /> C ITY of ORONO . <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> � - � � On the North Shore of Lake Minnetonka <br /> DATA PRNACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we would like 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 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 shared with other Iocal, state or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or I.icense requires Councii action <br /> to approve, some information may become public. <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 /> permit. <br /> +` 1�t� f��lV�C� J�'' �`f C=�t�--�F1 f2 � <br /> First Middle Last <br /> z t 7 7 �S�-f��`� �c�c� � KL c.7 <br /> Address <br /> �w��-2,.�;-� � �� ���' 3�� � <br /> City State Zip <br /> -�7 [� 7�� � <br /> Phone <br /> I understand my rights �as stated above. <br /> � <br /> Signature <br /> BUILDING&ZONING-473-7357 • ADMINISTRATION&FINANCE-473-7358 • PUBL[C WORKS-473-7359 <br /> ASSESSING <br /> € <br />