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Y ♦ , � <br /> � � (��['�'�' o� ��►(��1'O <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal O�ces <br /> • <br /> � _ � � On the North Shore of Lake Minnetonka _ <br /> DATA PRNACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of sub erm t o= <br /> da ta", w e w o u l d l i k e t o inform you that your request for a P r e u i r e <br /> l i c e n s e f r o m the Cit y of Orono or any of its depar tmen t s m a y Q <br /> you to furnish certain private or con fi den t i a l i n f o r m a t i o n. <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 that <br /> the City deny the permit or license. <br /> 3. The information may be shared withto processcthe permit or <br /> federal agencies to the extent necessary <br /> license. <br /> 4. If your requested permit or Iicense ublic res Councii ac��or. <br /> to approve, some information may become p <br /> �. You have certain rights under M.S. 13.Oa to review private <br /> data on yourself. <br /> 6. Your full name is required to procsss this application or <br /> pe�-mit. <br /> �c<�G � -er�� <br /> Middle Last <br /> First - <br /> c� �7� �� ��^C9�^-� ��`/ t� P <br /> Address <br /> � 70 �,.� �l /�"� ,�. S-��� �/ <br /> City State Zzp <br /> �/?/- �i��/ <br /> Phone <br /> I understand my rights as stated above. <br /> ignature � � <br /> BUILD[NG&ZONING-473-7357 • ADMINISTRATION&FiNANCE-473-7358 <br /> � PUBLIC WORKS-473 7359 <br /> ASSESSING <br />