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t ^ <br /> a <br /> x9 <br /> Sf^ry1� <br /> �� �� �: ��� CITY of ORUNO <br /> .� <br /> � f" �`� 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.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 license. <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 priva�e <br /> data on yourself. <br /> 6. Yaur full. name is required to process this apglicatian o� <br /> permit. <br /> � � � �� <br /> First Middle Last <br /> /��4y /�e��-�,�c,-� C�%r <br /> Address <br /> � � <br /> ��C r���G�r� ������r✓/ -5 S�3 5� <br /> City State Zip <br /> y�y - ��n-� J - <br /> Phone <br /> I understand my righ ?as stated above. <br /> � . <br /> `� . � �� � <br /> Si nature <br /> BUILDING&ZOIYING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />