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""'� q� �: ;.�'=Y <br /> .:- <br /> �� <br /> � CITY o� �R�l`�T(� <br /> . <br /> ,4 � r � <br /> � -� ' Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> ..,t,.'` � �a <br /> ���-:;ti � <br /> z .�s;5 r�.iY' .:^a <br /> �.;��, � x,x. -�.+ ,_. <br /> ��,�,�����'��° On the Nortlz 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 /> 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 wi3. 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 license. <br /> 3. The information may be snared 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 Councii act�or. <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 ful.I name is required �o process this application or <br /> permit. <br /> �� , /� <br /> �C�bi r1 �l,tnr�� [.� c'�1��'{��e <br /> First Mi dle Last <br /> � <br /> �C�-.�` 1 �����,-I �.jr� <br /> Address <br /> , � <br /> a• �;�-�c !rl N �" �-3'c / <br /> Cit State Zip <br /> � 75 -�`��0, <br /> Phone <br /> I understand my rights as stated above. <br /> `���..��� ;:� , ,�j .� j�C,'��sZ, <br /> Signature c <br /> BUILDING&ZONING—473-73�7 • ADMINISTRATIOPI&FINANCE — �73-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />