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„:. <br /> �i���r CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> � - � � On the North Slzore 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 /> license 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 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 /> Iicense. <br /> 4. If your requested permit or Iicense requires Counci� action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review prica�� <br /> data on yourself. <br /> 6. Yaur full name is required to process this applicatian or <br /> permit. <br /> /l/��c,Ur� � � /� Sc i�i.9i-LiZ — <br /> First Middle Last <br /> .�� 5 � �>��/>>c��'(�ii L c�> %��/�� <br /> Address <br /> rI � <br /> L/.i�j' 7�l � /-� �/� /1, .� _S _ , <br /> City State Zip <br /> �, ? , _ c� ; , 5 <br /> Phone <br /> I understand my rights as stated above. <br /> ;� ; 7 :; � � <br /> - ,�� i`' :_ <br /> ;� _ _ <br /> Signature " <br /> BUILDING&ZONING—473-7357 • ADMIN[STRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />