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. ' <br /> :�:; <br /> �� .. <br /> � 4: <br /> ` r�� �a CITY of O�iONO <br /> �:�� <br /> Post O�ce 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 /> 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 /> l. The information you furnish will 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 tha� <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 /> 3.icense. <br /> 4. If your requested permit or Iicense requires Council. action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�� <br /> data on yourself. <br /> 6 . Your full. name is required to process this applicatian or <br /> permit. <br /> ����.t � 1�;�/a�._�>i.t;��,,tif �'�N�i/v�C`:N�9�1 <br /> First � Middle Last <br /> � ,� � � <br /> ,�� ; r1Rn <br /> 1�ddress <br /> � ' ��a3 � <br /> 6��d �C.A<<,- � ,� �, <br /> City State Zip <br /> �-���� - C� ��i <br /> Phone <br /> I understand my right s stated above. <br /> �� � � <br /> �� � i . <br /> Signa <br /> BUILDING& ZONING— 473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br /> � <br />