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` . �I f �P.�.��n <br /> i J: <br /> }4 1� 'y <br /> � i�� <br /> �� �a CITY of ORONO <br /> ; �. <br /> ;;. <br /> �. <br /> + �; Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> r w.,. <br /> 4, <br /> A s�`4 ��°'��' On the North Shore of Lake Minnetonka <br /> ,r�; <br /> DATA PRIVACY 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 /> 1. The information you furnish will be used to determine your <br /> qualification for the permit or license 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 your requested permit or Iicense requires Councii action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�at� <br /> data on yourself. <br /> 6. Your full namP is required to process this apFlicaticn or <br /> permit. <br /> � � .�� 1�0 ������ <br /> �� i �c� ;a� , <br /> First Middle Last <br /> /y� <br /> /,r_��G/ ��c`' �!1�'�'7 L�'i►'' <br /> Address <br /> / i , n ` �3� <br /> �i�c'�! S i cv V' �'!�i/ .J �� - <br /> City State Zlp <br /> �j�y - y';c� �' <br /> Phone <br /> I understand my r' ts as stated above. <br /> , <br /> � - ���,_�- <br /> Si ature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINAIVCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br /> � � <br />