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... � <br /> � <br /> CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal O�ces <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 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 /> qua3ification 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 Iicense. <br /> 3. The information may be shared with other 3ocal, s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit 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 private <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> �_:- . <br /> �,.',1� '�' � �'T�. <br /> � <br /> First Middle Last <br /> _.., �„., - � <br /> �W ��,.. ,,,,;, a'.�t,.a ,a;`^ d,� ":r '{� .��� �'f'r '�"� <br /> Address <br /> ��--� ��:,- 'k�,� �: 4"«. �" � , � <br /> City State Zip <br /> <" ��y:, �1 . , � �% ��,; � <br /> �� <br /> Phone <br /> I understand my rights as stated above. <br /> �,,� ^�„� <br /> ' neture <br /> BUILDING&ZONING-473-7357 • ADMINISTRATIO[V&FINANCE-473-7358 • PUBLIC WORKS -473-7359 <br /> ASSESSING <br />