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� <br /> - ����' �� ���i�� <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 /> l. The information you furnish will be used to determine your <br /> qualification for the permit or I.icense 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 3.oca1 , 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 Council act�on <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 /> b �V�rJ �.l�w��N(/� roC��t�n�- <br /> First Middle Last � <br /> �ti�� 19 � ��C S <br /> Address <br /> �L� . �Vlrv- �� �a1 <br /> City State Zip <br /> '1�-�' �, ,-�' <br /> Phone <br /> I understand my rights as stated above. <br /> � � <br /> U <br /> Signature • , <br /> BUILDIIVG&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />