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�l . �� <br /> � A� <br /> � y"*,'Ia'�'t !�' � .'. n <br /> _ � �:'��C ;� : <br /> k �° `� {; CITY of ORONO <br /> - � t"�' r gv <br /> •, t <br /> Pv � � . <br /> '�rh <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> � _ � � On th.e North Shore of Lake Minnetonka <br /> DATA PRNACY 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 f rom 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 wi3.1 be used to determine your <br /> qualification for the permit or Iicense reguested. <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 with other iocal , state or <br /> federal agencies to the extent necessary to grocess 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 pri�a�� <br /> data on yourself. <br /> 6. Your full name is required to process this applicatian o� <br /> permit. . <br /> _--� ���.� �� �� � -� � �� �-z- �%t7 �L <br /> ; <br /> First Middle L t <br /> �" � � ' C—1 <br /> � ���= ��-�� ���ti � ti � � ; ,�� . <br /> Address <br /> �, �-�1 ti ��� � �� <br /> � � � <br /> �,� �� ,� ;, <br /> City State Zip <br /> �� --� � _ �-7 � � -, <br /> j �.J <br /> Phone <br /> I understand m rights as stated above. <br /> � % <br /> Sig ature i <br /> �' <br /> BUILDING&ZOIVING—473-7357 • ADMINISTRATIO[Y&FINANCE—473-7358 • PUBL[C WORKS—473-7359 <br /> ASSESSING <br />