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� . � <br /> �` <br /> =, ��'�'�' o� O��leT� <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> 0 <br /> s ' s o On the North Shore of Lake Minnetonka <br /> DATA PRSVACY 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 /> license 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 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 inf ormation may be shared with other Ioca 1 , s�ate 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 ac��on <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. Your ful.l name is required to process this application or <br /> permit. �� C�U � � � <br /> Gvv �w �� <br /> �w � � � L.�4-�� 1 <br /> First Middle Last <br /> l�o X' 2 3�0�- <br /> Address <br /> ���� � � e L�- ►�,� �v x� 4 .�� 4 23 <br /> City State Zip <br /> � �4 � SSa2- � <br /> Phone <br /> I underst d my rights as stated above. <br /> < � <br /> S ' gnature . ,• <br /> BUILDINC& ZONI�IG—473-7357 • AD�flNISTRATION&FIYANCE—473-73�3 • PUBLIC WORKS —473J359 <br /> ASSESS(NG <br />