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� <br /> �j~� � <br /> �` �� CITY of O�iONO <br /> �. <br /> � �..�� . <br /> .,�,�.� <br /> �� 5(M Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> • <br /> s� - � � 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 /> Zicense 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.l be used to determine your <br /> qualification for the permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with other Iocal , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Council ac�ior. <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> r data on yourself. <br /> 6. Your full name is required to process this appl.ication or <br /> pe?-mit. <br /> -� <br /> C l`\� i__ Q �� � ME2 �'iG S�l t C�i�c, C� (w2GL� A'�Iv'��rN� <br /> .� 1 <br /> First Middle Last � � '���t�l-�Gti� <br /> l���X � � � - <br /> Address <br /> �� �; �r � �7" �� 1 �. '; , , ,�`� �% -J", �--' �> "', <br /> Ci_ty tate Zip <br /> <�� ,� 7 __ � � �� �� <br /> Phone <br /> I understand my rights as stated above. <br /> -�i > <br /> ,// (��/ �./I � " — <br /> - f ^<<- ' <br /> `-� Si a- ure <br /> � <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINAVCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSI'VG <br />