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A ,. ,,t. <br /> �• <br /> � <br /> CITY of ORONO <br /> Poat Office Box 66•Cryatal Bay,Minneeota 55323•Municipal Offices <br /> • _ <br /> � - � � On the North Shore of Lake Minnetonka - - <br /> DATA PRIVACY ADVISOBY <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. ;. .y�. - , _ ._ _ <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 local, 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 pub3.ic. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�� <br /> data on yourself. <br /> 6. Your full name is required to process this apFl.ication or <br /> permit. <br /> �v-�,� ,� � ��,� L�C <br /> First Middle Last <br /> 3� � �` c.� �-o�c� S� <br /> Address <br /> ���'� W v�- � 1J S S 3 � <br /> City State Zip <br /> �,SS-- � �6 � - <br /> Phone � <br /> I understand my rights as stated above. - -.- : _ _ <br /> � _ _ , � - <br /> �- <br /> � � <br /> Signature `: '. __ ... <br /> BUILDING&ZONING—473-7357 • ADMIIYISTRATION 6t FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING , . <br /> � <br />