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. . -� <br /> ",,,,,,,,.� i q <br /> A �a F <br /> _ � �'��� �� {�� CITY of ORONO <br /> �ri�� � � <br /> � 3 ,oa§d �3r�k��r . <br /> .,`� '��r,.'�," <br /> Post Office Box 66•Crystal Bay,Minnesota 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 /> 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 3icense. <br /> 3. The information may be shared with other iocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Counci3. action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review prica�e <br /> data on yourself. <br /> 6. Your full name is required to process this applica�ian or <br /> permit. <br /> --� <br /> � i t-� !t�r������ f ���>�: � , t�� r��-F�ct���K <br /> First Middl.e Las <br /> f� ��- V���J`'�[l.`'�C' �d��'� � '/ f � �� `` <br /> Address <br /> ��l`�-�' �'�'r�l[ f���c l Ul � � ����� <br /> City ~State Zip <br /> ., � � <br /> C� /� ' <br /> , , <br /> , �� �.. <br /> Phone <br /> I understand my rights as stated above. <br /> /' � �` ; , L <br /> � �'i -- � <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />