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-. , �- _ <br /> �.� .�,� � <br /> ��� �. <br /> �:�. ��-��� O� ORONO <br /> .�. <br /> � �I�Y <br /> � Post Office Box 66•Crystal Bay,Minnesota 55323•141nniciPal Offi�es <br /> • <br /> � _ � � On the North Shore of Lake Minnetanka <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 /> 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 wil3. 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 Ioca1 , s�ate 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. ac��or. <br /> to aporove, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your full name is required to proc�ss this application or <br /> permit. <br /> r 1� � ���T�� �J��"�,� � (� y� �_SS��- <br /> First Middle Last ' <br /> ,���� �l � ��-e,�� t �.�� I� � � � -. <br /> Address <br /> �� c � <br /> �,,� � �-- � �d-��z c ���� � � <br /> �ty State Zip <br /> L� �? � � �� �� � <br /> Phone <br /> I understand my_ rights as stated above. <br /> � �--� � � C� ��" �, <br /> Signature � � <br /> , ' <br /> BUILDiNG&ZONING-473-7357 <br /> • ADMINISTRATION&FINANCE-473-7358 • PUBLIC WORKS -473-7359 <br /> ASSESSIN G <br />