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r � <br /> � <br /> C ITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minneaota 55323•Municipal Offices <br /> • <br /> � - � � On the North Shore of Lake Minnetonka <br /> DATA PRNACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we would 3ike 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 wil.l be used to determine your <br /> qualification 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 iocaZ , 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 Councii. action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�� <br /> data on yourself. <br /> 6. Y�ur full name is required to process this applicatian or <br /> permit. <br /> �� �1�t= c� ��4��:�L— �.-�1 k—��� <br /> First Middle Last <br /> ' �J� <br /> .� <br /> t�.�.', w � �"5 --> <br /> Address <br /> �,�;, ��I►��, ���z,�, <br /> City State Zip <br /> �r� `3 _ �`1 C%c� <br /> Phone <br /> I understand my rights as stated above. <br /> � �-�. l <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADML�IISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />