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,{' . ♦ a <br /> �:- j' .;;,; ,.t+� <br /> `I a. F + <br /> t F� ) <br /> � � <br /> 1�s � " �� �� C ITY of ORONO <br /> �' �� °�; <br /> �°s s_��a i ,� '. <br /> `� �''' � ' ' Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> a gr -�,� . <br /> .:a�1� ' r. <br /> '���jyk� 3 �': ') <br /> y��:-, ,� , ;,, , 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 /> 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 Iicense. <br /> 3. The information may be shared with other local , state or <br /> federal agencies to the extent necessary to grocess the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 �o review pri�a�� <br /> data on yourself. <br /> E. Your full name is required to process this apFlicatic:� o� <br /> permit. <br /> � u � � � �.�j' r��.:"'� ` �_ ��'� �'� � � — <br /> First Middle Last <br /> ��i � �'���r� .. :�'� L,��`� ���v C � <br /> Address <br /> ,;�:.. �� Z�_,� �._ i'��� % % � `'� 1 <br /> City State Zip <br /> �� � � � ��, �E�, � <br /> Fhone <br /> I understand my righ� ,s tate a ve. <br /> � <br /> r" <br /> �f t <br /> �'�'� i - <br /> � 6 �� <br /> Signature ' <br /> BUILDING&ZONING—4%3-7357 � ADMINISTRATION&FINANCE—473-7358 � PUBLIC WORKS —473-7359 <br /> ASSESSING <br />