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� <br /> CITY o� ORONO <br /> Post Office Box 66•Crystal Bay,Minneaota 55323•Mnnicipal Offices <br /> • <br /> � . � � 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 like 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 /> l. The information you furnish will 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 license. <br /> 3. The information may be shared with other 3.oca1, state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or l.icense requires Counci3. action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review privat� <br /> data on yourself. <br /> 6. Your fu1.I name is required to process this application or <br /> permit. <br /> 1�01,..« �b � '�-�..,��+D+�'��... S 1�j�V ��� <br /> First Middle La <br /> � "�� � �'.'! �'C�c� t��.� t�.---�```� _ <br /> Address <br /> ""� �1 �:.�-'�►,� c-`t �� ,�""��3 1 - <br /> City State Zip <br /> ,� � <br /> Phone <br /> I understand my rights as stated above. <br /> ��r t .,,�� "�,,. <br /> __ - ;�eb � ��� �,, <br /> Signature , <br /> BUILDING&ZONING-473-7357 • ADMINISTRAT'ION&FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING - <br />