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;,�.°�^,,,�y, <br /> �... ��,�,��,� ��x� �-- <br /> � � •:.;�?'r <br /> ���µ �. � . !Y.��� �`�� �i��� O� ����� <br /> 'SS+ .SFa�;�SEy ?;;tT N'.�.. <br /> � ,_�,.,`"-�,3: Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal 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 /> Zicense 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 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 process the permit or <br /> license. <br /> 4. If your requested permit or license requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to revzew prica�� <br /> data on yourself. <br /> E. Your full name is required to process this a�t,3.ica�iaa or <br /> permit. <br /> � ��� <br /> ...�-4-.��:�,o. ��� � <br /> First Middle Last <br /> L� '�k�� L�.�....`.�-�."F �:'�--�-- �.�.,��__.___ `�� <br /> Address <br /> V�;c�.�;�\c� ✓�-1. � �d�f� �z� <br /> City State Zip <br /> �a���J ` �S`.{ `?�' <br /> Phone � <br /> I understand my rights as stated above. <br /> t=� <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FIN�INCE—473-7358 � PUBLIC WORKS—473-7359 <br /> ASSESS[NG <br />