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., , <br /> _;� <br /> ,� ���: �t <br /> . �.��7'r�r-• . ^r� ''. <br /> ;����� �� C�'�'�' o� O���TO <br /> _� -,: 3 .�;�`�'' <br /> �_�_ <br /> ,,;;��.; <br /> ���:, r.;a� <br /> T'`a�..a.�..r .� -�'�,.-w.-.. <br /> Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> ':��� �_ o '-.< 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 3.ike 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 yaur <br /> qual.ification 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 with other Iocal , 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 full name is required to proc�ss this application or <br /> permit. <br /> u._.. ....... � <br /> �� „-��;`„�� 1�� C�'1 !'�G - <br /> First �' Midc�le Last <br /> � � � <br /> � ,� �._ `_ � <br /> / --� � -�->ii Ir 7��� f.� G' � � <br /> Address <br /> C-��'�'%l�L�...; /" �, ,�:� ,� �� <br /> City State Zip <br /> � �/ , � <br /> ! ��__ �� ,�'-; <br /> Phone <br /> I understand my rights as Stated above. <br /> , , <br /> :-� <br /> ,-� � � ���� <br /> r � 'i „�� �' ,, <br /> - a�.L L�. �=� ` <br /> ignature • <br /> BUILDING&ZONING—�173-7357 • ADMINISTRATION& FINANCE—�73-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />