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. � � � � <br /> � <br /> . � _ - i <br /> - � <br /> ���� O� ���1�� <br /> s!!R�1"<1� <br /> Post Office Box 66•Crystal Bay,Minnesota 5a323•Municipai l?2nces <br /> • <br /> s - m � On the North Shore of Lake Minnetonka <br /> DATA PRIVACY A�YISORY <br /> In accord�nce with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we would 3ike ta inform you that your request for a permit or <br /> license from t�►e 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 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 aqencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or I.icense requires Council action <br /> to approve, some information may become publ.ic. <br /> 5. You have certain rights under M:�. 13.04 to review pri�a�� <br /> data on yourself. <br /> 6. Your full na::e is r�q��i=ed to process tnis appZication or <br /> permit. <br /> ���0 � � ���v� <br /> r^irst � Mi:d'e Last <br /> �/� �t������ �� � � �' <br /> Address <br /> I,l) �-,�-� /�tt/ .s S.3�/ <br /> City State Zlp <br /> �7�,�1�a � <br /> Phone <br /> I under tand my rights as stated above. <br /> �-- <br /> . <br /> Signature • � <br /> BUILDlNG&ZONING—473-7357 • ADMIN[STRATIOIV&FINANCE—473-7358 • PUBL[C WORKS—473-7359 <br /> ASSESSING <br />