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_ . i <br /> r <br /> �- �' - �'��' �� ���NO <br /> � <br /> W� Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> . s � <br /> e _ � � 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 f rom the City of Orono or any of its departments may require <br /> you to furnish certain private or confidential information. <br /> - =r�li ure netified that: - . . <br /> l. The information Y e�t or Iicensebrequested. determine you�— <br /> aual.ification for the p <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 wiyh ot�her Iocal , e�it or <br /> f ederal agencies to the extent necessar to rocess the p <br /> license. <br /> 4. If your requested permit or Iicense requires Councii ac��o% <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 ful.l name is required to process this appl-ication or <br /> pe_ t. _� / � 1 <br /> � � J�y r���s�,� <br /> First Middle Las <br /> �c� � C��������-L����� ��� �'���= s, _ <br /> � <br /> Address � /f//l' <br /> �' ;� s- ���J� s � -/ <br /> f <br /> Cit State Zip <br /> �/� - ��/- ���.� <br /> Phone <br /> I underst my righ•ts s d above. <br /> / / ' <br /> , � <br /> �� . �, <br /> �, �,;+��� - ,�.,�i'�`��''���-- <br /> Sign tu e � <br /> ! <br /> BUILD[NG&ZONING—473-7357 • ADMINISTRAT'ION&FINANCE—�t73-7358 <br /> • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />