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1 <br /> CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minneeota 55323•Municipal Offices <br /> , ..:.. <br /> • <br /> � - � a On the North Shore of Lake Minnetonka -� <br /> DATA PRIVACY ADVISOBY <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 /> 1. The information you furnish will be used to determine your <br /> gualification 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 Iicense requires Council action <br /> to approve, some infarmation may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�e <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> 1C��1(t-b � �� l-CM <br /> First Middle Last <br /> a ��� �U � � <br /> Address <br /> l,P�((`� �., � 3� � <br /> City • . State Zip <br /> ��3��t c� I - -� <br /> Phone � <br /> I understand my rights as stated above. - <br /> . . ;� _. . _ • <br /> � <br /> �-, _ __ . . <br /> Signat re .�� �_ ; _ <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473•7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING , . � <br />