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� . � _ s <br /> �. <br /> � <br /> �t � d, <br /> �,Q�„ �,a� 4 � �i��� O� ���1�� <br /> .�%�` k. '{ r�.. <br /> ; Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> � <br /> � _ � 0 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 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 wil.I be used to determine your <br /> qualif ication f or the permit or I.icense requested. <br /> 2 . You may refuse to supply data, but refusal ina� require that <br /> the City deny the perr,iit or Iicense. <br /> 3. The in�ormation may be shared with other local , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> a_, If your reauested permit or 3.icense requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review prica�� <br /> data on yourself. <br /> E. Yaur fu'_I r.ame is required to process this applica�icn o� <br /> permit. <br /> � �,_ <br /> ,� ,j � .�) � ` ��.4�i <br /> First Middle La t <br /> �vj �� !`�<��.����� ��., <br /> Address <br /> � <br /> • �%���� l �;"� �r--- <br /> ity State Zip <br /> ��� �� ' �l`�i�' / <br /> :� / <br /> Phone <br /> I under n my rights as ted ab e. <br /> , <br /> ,,- . _ _ <br /> � � <br /> ,/" <br /> Signat e <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINAYCE —473-7358 • PUBLIC WORKS—473-7359 <br /> ASSES3ING <br />