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. <br /> � <br /> CI'�"Y O� O�►'ONO <br /> Post Office Box 6&•Crystal Bay,Mianesota 55323•Municipal Offices <br /> . � . <br /> � _ s � On the North Shore of Lake Minnetonka _ <br /> DATA PRSVACY ADPISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we would like 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 will 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 license. <br /> 3. The information may be shared with other local, s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Councii ac��or. <br /> to approve, some information may become public. <br /> �. 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 /> � a �� ���-� � � 1 S o —� <br /> First Middle Last <br /> � � � y s� a�� ��� � �� <br /> Address <br /> �a�a��-e /� �✓ 5�3 � Z <br /> �ity State Z1p <br /> 6�iZ� �f 7/ - � j`� � <br /> Phone <br /> I understand my rights as stated above. <br /> < <br /> ` " � �,-�, <br /> Si nature � � <br /> g <br /> BUILDING&ZONING-473•7357 • ADMINISTRATION&FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />