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�. <br /> � ,n � ,e <br /> �t �,� � <br /> � µ CITY of ORONO <br /> � �r«,.Z; �; <br /> .�, .�...s6c..bi.t4 <br /> �,��� ��; �� �'" Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> .,,:� „.w�.��a�;.:.,?b'd.... <br /> �-t�! ��.�_ ' <br /> �����°'�` On the North Shore of Lake Minnetonka <br /> b ;� - � a: <br /> � <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 /> license 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 license. <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 /> Iicense. <br /> 4. If your requested permit or license requires Council action <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 to process this application or <br /> permit. <br /> , ,., <br /> �'�<t=- .� ' �-'�-%'�'•'` <br /> First Middle Last <br /> �� to i� z� �u• ,� lc�T <br /> Address <br /> ..� L i <br /> U'�� ��, c� 1��`"� �� � � I <br /> City State Zip <br /> �-��1� � -- � �t�`� <br /> e <br /> Phone <br /> I understand my righ as stated above. <br /> �--�_ <br /> �, <�' �' <br /> �(_,'� �r ��4%� �� <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />