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. a <br /> ' "'�*�,a` .�_.� <br /> t <br /> �� CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minneaota 55323•Municipal Offices <br /> • <br /> � - � � 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 like 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 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 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 Councii 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. Y�ur ful.I name is required to process this appl.icatian or <br /> permit. <br /> -% <br /> �'��� '� l•G� . �,) � �C��-'y��;� i, !. ' <br /> First iddle Last <br /> L��3� ��� �L� �� �'" <br /> Address <br /> --�',, <br /> � f ^ //" / �'� �-' -5 ,� <br /> Ci �y State Zip <br /> . __ �-�`^' /__ 7 � `'�� <br /> = �- <br /> Phone <br /> I unde and"my rights �.s s�.at`d abov . <br /> %� � /i� �� <br /> �� ,�,, ,�,� � ;�,,,:�:, - _ <br /> `, <br /> S ' gnature i� � ' <br /> � <br /> BUILD[NG&ZONING—473-7357 • ADMINISTRATION�&.FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />