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I► � �✓ <br /> ci�rY of oRoNo <br /> Pos!OE�ic6 Bolt 68+Ctystal Bay,Minnesota 65323•Mnnicipal OfSc� <br /> � <br /> � . � � On the No�th Shore of Lak�e Minnetonka <br /> DATA PRIVACY ADVISORY <br /> In accordance with �I.S. 1�.04,` 3u�d� 2+ "Rights of sub jects of <br /> data", we would like to inforM �t�1� �hgt ycur request for a permit or <br /> license from the City of Orond or �tny�of 3ts departmerits may require <br /> you to furnish certain private or` �oi�fidential information. <br /> You are notified that: <br /> 1. The information �ou furr�ish will be used to determine your <br /> qualificatfon for the permit or license requested. <br /> � - <br /> 2. You may refuse to suppl�' data, but r�ft�sal ingy rec�uire that <br /> the City deny the permit or license. . <br /> 3. The information may be� �ha�ed with other local, state or <br /> federal agencies to the ert��h� he�ess�ry to proces� the permit or <br /> license. � <br /> 4. If your requested permft or license re,q�ites Council sction <br /> to approve, some informatit�n m�� become,public. <br /> 5. You have certain `r�ght�` undcr �M�S. 13.04 to r�view priva�e <br /> data on yourself. <br /> 6. Your full name is reqi�ited to process th�is application �or <br /> permit. . <br /> J�i��-('�,i�� ,,�1�1-�-� ��-!,T(/� <br /> First Middle - < Last , <br /> �`��f�� li!��lAl�l`� bl�� �/'� �f`�D --- <br /> Address � <br /> �I I�� 1>'f til , ,.��.: , ���-f�3tD <br /> City , Stat��' . , Zip : <br /> 4?,��� J 2.4' " �,Ye_,r' t, rr < , , <br /> Phone , <br /> :�.�, ,_ _ . <br /> I understand my riqht�� as" t�tllt�d sbove. . <br /> , � Y .�� � <br /> .,, � _., . <br /> � �'___ , �������' �,. <br /> S ga . re� . <br /> BUILDING�ZONING—473-7357 � ADMINISTRA770N�FINANCE—473-7358 + PUBLIC WORKS—473-7359 <br /> ASSESStNC � <br />