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. � - ' <br /> f <br /> •`' � <br /> � ��'_��.'o� ���I�T� <br /> Post Office Box 66•Crystal Bay,Minnesota 5a323•Municipal pffices <br /> 0 <br /> s - s 4 . On the North Shore of Lake lifinrcetonka <br /> DATA PRSP�CY 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 /> Iicense 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 r=�uested. <br /> 2. You acay refuse to sunply data, but re=usaZ may require that <br /> the City deny the permit or license. <br /> 3. The inf ormation may be snared with vtzer Iocal. , s�a�e or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> a. If your requested perinit or Iicense =BCL71Z"eS Councii ac��o% <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.C� to rev�ew grivate <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> pe=-mit. <br /> S�r�v �l � S�-�-�� I <br /> First Middle Las� <br /> O�s � � J � S I � �- <br /> Address <br /> ���,�3 c� 1�/1 v�j ��`�3 � �- <br /> City State Zip <br /> `�7�� 2 J y .�-� <br /> Ph ne <br /> I u erstand my 'ghts as stated above. <br /> S ' gnature . ' <br /> BUILDING& ZONI�G -473•7357 • AD�tINiSTRATIO�I&FINAVCE-473-73:3 • PUBLIC WORKS -473-7359 <br /> ASSESS[NG � <br />