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. .,�'�av"''�,, <br /> � . � <br /> 1 I 4'.M1. . l . � <br /> i <br /> �'��i�.._ <br /> , .Wnu�.4xi 1�-. �� . <br /> ,Y{e� � VAtY4 � ���� o� ����� <br /> v�i n. W x �� <br /> .n .'�#«ef�t$�;:.,: r <br /> r z�y3 3� 1� •,s+rp.. <br /> "°°� '}'.'��'� Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> �:.""�� �, �;�a, <br /> � - a �;. 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 3ike 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 /> l. The information you furnish will be used to determine your <br /> qualification for the permit or I.icense 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 Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�� <br /> data on yourself. <br /> 6. Your full name is required to process this appl.ication or <br /> permit. <br /> �F�,� •��� � ��''�-�G�,-�._J <br /> First Middle Last . <br /> � v�s- .s��.-►..�.�.,..�._. (,2�v- <br /> Address <br /> -�N �35 � <br /> Cit State Zip <br /> �7.s":���y.� <br /> Phone <br /> �derstand my rights as stated above. <br /> � <br /> ignatu <br /> � ; <br /> BUILDING&ZOIYIIYG—473-7357 • ADMINISTRATION&FINAfYCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />