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1 ' .� � . <br /> .:.�e <br /> `A�•-'+��,�x '� :. .i <br /> w � aS +� �r:$:X,�'�. <br /> .,. { �� 1�� �4�. ..' <br /> � � � � C ITY o� ���N� <br /> �� <br /> �.: :. <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> 0 <br /> � - � � On the North Shore oj 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 confidentia]. information. <br /> You are notified that: <br /> l. The information you furnish wi3.1 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 Iicense. <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 license requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�� <br /> data on yourself. <br /> 6. Your ful.l name is required to process this application or <br /> permit. <br /> . _ _ <br /> � - --� `;> e.. � � `%ti..i L � �V;_ ��i � <br /> First Middle � La'st � <br /> �:' � > `� l�s ��.� `� f>%� L �: i' )l �� _ <br /> � <br /> Address <br /> , � � _ . <br /> ���� � �� � �� �. � � ��. <br /> � �, <br /> City State Zip <br /> . _�- �7� -.-� �. ;i � <br /> Phone <br /> , <br /> I understand my rights as stated ;�bove. <br /> � ��r ' ��r�-��� <br /> � L/��!���/ �/?�/C��' ! <br /> / <br /> Signature � <br /> ( <br /> BUILDING&ZONING—473-7357 • ADMIIVISTRATION 8c FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />