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: �. <br /> _ .��� , ��'��' �� O���TO <br /> . � <br /> 41 Post Office Box 66•Crystal Bay,1�finnesota 5a323•Municipal Offices <br /> � <br /> � _ � � On the North Shore of Lake Minnetonka _ <br /> DATA PRIVACY ADVIS�RY <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 perm ioe <br /> license from the City of Orono or any of its departments may req <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish wil.l 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 , s�ate or <br /> f ederal. agencies to the extent necessary to process the permit or <br /> Iicense. <br /> a. If your requested permit or Iicense requires Councis ac��or_ <br /> to approve, 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 process this application or <br /> permit. <br /> JO G, �, � 1/o�-�'P � <br /> First <br /> Middle Last <br /> 3y�1� 5�1��0 �� ►� �� • <br /> Address <br /> � � v d � � -� Yyl � �`s 3�z._- <br /> City State ZiP <br /> � 7 � � ��� � <br /> Phone <br /> I understand my rights as stated above. <br /> � <br /> Signa ur � • <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINAIYCE—�73-7358 <br /> • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />