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� � <br /> CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minaesota 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 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 furnish certain private or confidential information. <br /> You are notified that: <br /> l. The information you furnish wiZl 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 Iicense. <br /> 3. The inf ormation 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 Council act�on <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> �iS/d>) G�'�D,���S a.�/ <br /> First Middl.e Last <br /> ���� ��v�� t/'/c� /.�� <br /> Address <br /> Gv/� i- /�� S'SS.�'�� <br /> City State Zip <br /> �T /,Sr�D�� <br /> Phone <br /> I unde a my rights as stated above. <br /> � <br /> Signature <br /> BUILDING 8c ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />