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w, <br /> ^���� <br /> f- ���'; `�. <br /> k� CITY of ORUNO <br /> �i� 2��`������ <br /> 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 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 license 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 actian <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 /> E. Your full. name is required to process this apglicatian or <br /> permit. <br /> C� <br /> '�`l�o�,��. S����.�'+C�`:`Y,�r� L.� _ <br /> First Middle Last <br /> � �� � ��� � � a <br /> Address <br /> ��:�,ti�� ,�E� � �S - ��- �S�i �� <br /> City tate Zip <br /> ���_~ �����(J <br /> ) <br /> Phone <br /> I understand my rights as stated above. <br /> `�.. <br /> . �� - <br /> � -�-��-�-r--� <br /> Signature <br /> BUILDING& "LONING—473-7357 • ADMINISTRATION&FIN�NCF.—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIti G <br /> � <br />