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r h <br /> :�':_,. <br /> � ..� �. <br /> �,. "�� <br /> ,� ���� ��' <br /> cPz��cb�s�����.�..,.� �� <br /> x� �x�����'�� ���� �� ��� <br /> s,�;.� �`` , r < , � <br /> � <br /> ^�� _ . f��_ Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> 6�:.,. �,-r� '' �;. <br /> Tf��:: . t�J , . <br /> `���� ��' On the North Shore of Lake Minnetonka <br /> h <br /> DATA PRIVACY 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 f rom 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 Iicense 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 local , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or bec me e ub q�ires Councii actior. <br /> to approve, some information may P <br /> 5. You have certain rights under M.S. 13.04 to review priva�e <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> �� � ��� �- �.� �` ("r-i � ,1 � i � � <br /> �, � 1� � � : �� �. - � � �, <br /> a iddle Last <br /> irst -� -� <br /> � -� .- . <br /> � _ � --, � � ���� I 1 ►• � � � � <br /> _-, �; _ <br /> Address - <br /> r �' � -S-� ��/ Z- <br /> HL �} y i. �_ l�/. � ' <br /> City State Zip <br /> �; i�- -- y � 1 � ��� y �� : <br /> Phone <br /> I under�and my rights a,� stated, a�e- <br /> � / : �. �� <br /> , , , <br /> , , , <br /> >� � <br /> - ��j� �.,, <br /> �� � � . , �;��� �,: _ ���- .. <br /> � , -, /;'; , <br /> gnature <br /> BUILDING&ZONING-473-7357 <br /> • ADMINISTRATION&FINANCE-�73-7358 • PUELIC WORKS -473-7359 <br /> ASSESSING <br />