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� 1 <br /> _ � <br /> � � � (����.' o� ��►��T� <br /> «� Post Office Box 6&•Crystal Bay, Minnesota 5a323•Municipai Qffices <br /> ! <br /> • - • • <br /> On the North Shore of Lake Minnetonka _ <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13•ou`that your request for a perm t or <br /> data", we would like to inform y o f its departments may require <br /> license from the City of Orono or any <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 snared with ot rOCe scthe permit or <br /> federal agencies to the extent necessary to p <br /> Zicense. <br /> a. If your requested permit or Iicense requires Councii ac��o% <br /> to approve, some information may become public. <br /> �. You have certain rights under M.S. 13.04 to review griva�e <br /> data on yourself. <br /> 6. Your full name is reguired to proc�ss this application or <br /> pe=-mit. <br /> J J�Y��'l� <br /> First <br /> Middle Last <br /> ���1� �S�C lc-n� ���-� <br /> Address � ^ <br /> � �G ��� � ��� � <br /> City State ZiP <br /> ���- a�� <br /> Phone <br /> I under ta d my rights as stated above. <br /> , l�L� - <br /> Signature � • <br /> BUILDING&ZONING-473-7357 • ADMINISTRATION&FINANCE-�73-7358 <br /> • PUBLIC WORKS -4�3-�359 <br /> ASSE55ING <br />