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i :��. <br /> �aa,..'P S.,'�>��� �x�.,�..K.. <br /> j A <br /> � � �' <br /> . � Ci�'�Y O� ���1�� <br /> � Aq SAK^�:��k �� S��i� <br /> �.1'a Ar.t� ;'� <br /> �;�� � A.�. <br /> �.t-a Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> , �� <br /> ,t.,., t�.9 <br /> s'� On the North Shore of Lake Minnetonka <br /> .a�- � • <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 /> license from the City of Orono or any of its departments may require <br /> you to fur.nish 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 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 Iocal , state or <br /> federal agencies to the extent necessary to �,rocess the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 �o review pri�a�� <br /> data on yourself. <br /> E. Your full name is required to process this apt,Iica�icn or <br /> permit. <br /> ��j✓ ,G�/�✓,Q BWN'E.�/�E/'2 <br /> First Middle Last <br /> �,30� ���ysa�� ,or� .�a <br /> Address <br /> � �� ss�.27 <br /> City �►,1�yD/�C State Zip <br /> l�L ,Sf�• O��' <br /> Phone <br /> I unders d my rights as stated above. <br /> Signature <br /> BUILDING&ZONING—473-7357 � ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />