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. <br /> � <br /> C ITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minneaota 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 /> l. The information you furnish wil.l 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 /> license. <br /> 4. If ycur requested permit or Iicense requires Councii. action <br /> to approve, some information may beccme public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�e <br /> data on yourself. <br /> 6. Yc,ur full name is required to process this apF-licatian or <br /> permit. ,� � <br /> /j=J1/J� �11 �J��'S ���'t S .' /L��/�I Jl'6� <br /> �. %� � l_ .:r 1`��.�� �/ <br /> irst Middle Last <br /> � t�C> l� �N <br /> � �� e �, � � <br /> Address <br /> y�' � s � � � <br /> , <br /> City t Sta e Zip <br /> �/�J � - � �� `�' � L� 1/ <br /> Phone <br /> i <br /> / <br /> I u stand m r' g s as stated above. <br /> . �������'�-l2 � <br /> ��/l� , � <br /> . �, <br /> ignature " <br /> BUILDING&ZONING-473-7357 • ADMINISTRATION&FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />