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� � + <br /> r �� � f � q 4 <br /> �f 5 a � CITY of ORONO <br /> , , <br /> � � <br /> , � <br /> �,_ a, �.-;�„a .;.,;� Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> � <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 /> 1. The information you furnish wi3. I 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 , 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 action <br /> to approve, some information may become public. <br /> �. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your fu1.I name is required to process this application or <br /> permit. <br /> �� .�— '�_"� �.'"".' d�c�C! ��'��'"' �- <br /> a: r <br /> First Middle Last <br /> �� .. .-- � �� <br /> /=�� ���.-, y <br /> Aadress <br /> , � „ _ <br /> l�� --� < . <br /> �,,--.�L'L- � ��'� �L�_ �' 7 <br /> City State Zip <br /> �_f -� J ---- �-�% �j"L� <br /> Phone <br /> I understand my rights as . stated above. <br /> �� , , ' ',� <br /> . , �,���,,.v <br /> Signatu / <br /> i <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FIN�YCE —473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSIN G <br />