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! • .�:'�'n"'"`�.,. <br /> ,. <br /> i <br /> "�"`,9: �\ ��'F5� .�il. <br /> w. W� � <br /> , b.���. �. - ��'��' �� ����'�T� <br /> ,F�z'S`. 3 ,�',' <br /> S.,.i�:e.� -= <br /> £�}4'� � � Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> :�"` - <br /> 3'" <br /> � s � � ,�; On the North Shore of Lake Minnetonka <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 /> 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 /> 1. The information you furnish wil.l 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 Iicense. <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 I.icense requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review prica�� <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> ` ' ���e�� _ � � I � ( �e <br /> First Middle Last . <br /> oZ�1 � � �,� � ve � Vi �w .b ✓' - <br /> Address <br /> � f0 ��v � � 5�35G <br /> City State Zip <br /> �.�y y -d v � /r <br /> Phone <br /> I understand my rights as stated above. <br /> , <br /> , � <br /> �.� ><�; <br /> ` Sign ture <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBL[C WORKS—473-7359 <br /> ASSESSING <br />