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� , <br /> ,�-�� CITY of URONO <br /> ,,_ - <br /> Post Office Box 66•Crystal Bay,Minaesota 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 Iike 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 will 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 local, s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> S.icense. <br /> 4. If your requested permit or I.icense requires Council act�on <br /> • to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�e <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> M I�.t-t D�� �. �'�� <br /> First Middle Last <br /> t&�2- �►,.�',�o�v� A�- <br /> Address <br /> v✓G��`� M►-� 5�rt 25 <br /> City State Zip <br /> ����Of0�1 <br /> Phone <br /> I understand my rights as stated above. <br /> � <br /> .� <br /> Signature <br /> � ...� • <br /> BUILDING& ZONING-473-7357 � AD�fIN1STRATiOr�.FINAYCE-473-7358 � PUBLIC WORKS-473-7359 <br /> ASSESSIN G <br />