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� . <br /> � <br /> CITY of OR�NO <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 like 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 suppl.y data, bi�t refusal may require that <br /> the City deny the permit or license. , <br /> 3. The information may be shared with other Iocal , s�ate ar . <br /> . federal agencies to the extent necessary t�o process the permit or <br /> license. <br /> 4. If your requested pe�mit or Iicense �requires Councii act�on <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�e <br /> data on yourself. <br /> 6. Your ful.l name is required to process this appZication or <br /> permit. <br /> � �L��l� t�� G��� �1��_ . <br /> FirSt Middle Last <br /> —1 • �' �x ��� � �� ��Z`�if �' I W 1G[/�I/ �Y Fi. <br /> Address <br /> . ���s� �� ��3� <br /> City State Zip <br /> ���-- 2�C� <br /> Phone <br /> I understand my ri hts as stated above. <br /> Signatu e <br /> BUILDING&ZONING—473-7357 • ADMINISTRAT'ION&FINANCE—�t73J358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />