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� . . , # <br /> ,� z ���� <br /> yd� � <br /> ��'� �iI�Y O� oRo�� <br /> ',r-r Y F� <br /> f �� � �� Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Officea <br /> 3 : � <br /> Y ...+�h'�y'$sA r�. .� • <br /> �� �`�" ` On the North Shore of Lake Minnetonka <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 /> Iicense f rom 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 wil.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 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 Iicense requires Councii. action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�e <br /> data on yourself. <br /> 6. Yaur full name is required to process this applicatian or <br /> permit. <br /> 6RcC�c�� � f�z z.�nl ��K� _ <br /> First Middle Last <br /> /3S �'� �tr�.��� ��t2��- <br /> Address <br /> ��LC��r�`Zr �in1 .�'��� 7� <br /> City State Zip <br /> r�;� z ) ��s= ����7�' <br /> �e <br /> I understan my rights as sta`ted above. <br /> Signatu <br /> BUILD[NG&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING ' <br />