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�� <br /> � F <br /> J t ' <br /> � � :�j, ��� 4 <br /> W"f,�f <br /> � � i y;,� <br /> �'4` � � �_ <br /> �`.���~�..� ���- CI�'�' of O�ON� <br /> _ �,p-�ar� .� .. <br /> �.-»'�'�>.a;�.z ° - <br /> �s:€�;. �, <br /> � �� �'�" .'` Post Office Box 66•Crystal Bay,Minnesota 5a323•Municipal Offices <br /> 4�.r n+�. <br /> ' ^`t�h <br /> � _ v �, 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 wi3.I 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 other Iocal , s�ate 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 act�or. <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your full name is required �o process this application or <br /> permit. <br /> � A�L,rz,J __�x �-/m r �% <br /> First Middle Last <br /> ! y� � �tf��� �-f P�- <br /> Address <br /> �C� V�.� t�� ��' •7 ��J �- � <br /> City State Zip <br /> ��� - d�� � <br /> Phone <br /> I understand my rights �as stated above. <br /> � � C� � ' ` <br /> Signature . <br /> BUILDING& ZOtiING—473-7357 • AD`tIN1STRATION&F1NArCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSIti G <br />