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� <br /> � Fa�%'F �� ; c . , <br /> �x �� ti <br /> i ���r <br /> x',t"�"�" �„ ,.�a,�. <br /> �� �V .�.` � C I�'�" of ORO1�T� <br /> - -x� �«�.:e. <br /> �s+.t.-'Y.f�^_e 't'v:i�'7 <br /> ,�� ._T�,v1 at;.4s.. <br /> .. +.� a. � +�r-.;,�.'.Y'r. <br /> ` � Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> .:,..:•,_, <br /> ` ��,`; • <br /> �'Y��` On. the North Shore of Lake Minnetonka <br /> ,. � _ • • <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.I 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 shared with other Iocal , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> I.icense. <br /> 4. If your requested permit or Iicense requires Councii ac��or. <br /> to approve, some information may become public. <br /> 5. You have certain rights under ri.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your full name is required �o process thiG application or <br /> permit. <br /> . <br /> > ,� <br /> / <br /> First � Middle Las <br /> �i��� l�l�c� �"���n,- � `'� - <br /> Address <br /> , �,� �r /�/� I�!/[/ 5 � � �' �>' <br /> City State Zip <br /> ,�3 i�%,��, <br /> Phone <br /> I understand my rights as stated above. <br /> t <br /> �'�� - �� <br /> i ature <br /> BUILDING&ZOtiING—473-7357 • AD}t[NISTRATION&FINAVCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSItiG <br />