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� <br /> _ r � <br /> � � � �'� �''� � ����� <br /> " �� � �I'�7�' O <br /> t Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal OfSces <br /> � <br /> � _ � o 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 like to inform you that your request for a permit or <br /> license f rom 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 wi3.3 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 information may be shared with other local , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii ac�io% <br /> to approve, some information may become public. <br /> �. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6, Your full name is required to proc�ss this application or <br /> permit. <br /> '� � � � � �i L "/'� �^ � � <br /> � � ,f � / <br /> t-� � i� /� j � �� . Last <br /> First Middle � ;/- <br /> ,. � _% __ , . <br /> . -> � <br /> /,'' <br /> Addr�ss �,� � ,, , _, � � <br /> � <br /> _ �' �i � ,L� ��� �, ', <br /> �_ �,-_ <br /> City S�ate Zip <br /> � � ; � �' � <br /> Phon <br /> I understand my rights as stated above. <br /> , <br /> � � <br /> � <br /> ,R'', <br /> �/� �� ,,V � / � . ,/Z' <br /> Signature � � <br /> BUILD[NG&ZONING—473-7357 <br /> • ADMINISTRATION&FINANCE—�173-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />