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} �, <br /> � . . <br /> �:_, , � <br /> �� �. �� 3�,,ti,,�: <br /> �����+�� �{���w CITY of ORONO <br /> ������t } 5 . <br /> ::.��� <br /> ���::. <br /> ��`�� '�' ` " `Y� Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> A:: • <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 f rom 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 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 local , 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 Councii ac�ior. <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�-� �� L� � � ��:��r� ,--�_=�1� C� c t� <br /> First Middle Last <br /> ,� �� _.-��� c'�� ��� �� �?c � <br /> Address <br /> _ L� L_'_�! � l- l ��- �>�� ->_�� / <br /> City St te Zip <br /> �� 1 :� - 1/J11 � � �, `� <br /> Phone <br /> 2 understand my rights as stated above. <br /> , <br /> � - _ -_-� -. -` <br /> _.�.. , - __�._ ._ � <br /> 4_ -- � <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />