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. <br /> . <br /> ,z3z.c - w <br /> �RE�'�� 4 <br /> ��� �,i� <br /> J��� � _ �i��� O� ����� <br /> -�-� _ <br /> .:�-� <br /> '''.��. ��' ' Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> : . � <br /> � _ <br /> `, � _ � g,. 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 3ike 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 /> l. 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 Iicense. <br /> 3. The information may be snared with other local , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii ac��o% <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 /> p e?-mi t. � <br /> r , <br /> n ^ <br /> �� , � / ��.S� � A <br /> irst � iddle !� Last <br /> / /���:�- <br /> _ J , , , � <br /> Address � /� _ _ <br /> �� � Y / ��� `�-��v��: <br /> ity State Zip <br /> � ��'�� <br /> �� _- � <br /> Phone <br /> I understan rights �ta�e� ab e. <br /> � ,,�� � <br /> � � c� � ��� _ � <br /> < <---� c` li C.�E--�'` <br /> Sig ure . <br /> i • Dbf1NISTRATION&FINANCE—473-73�3 • PUBLIC WORKS —473-7359 <br /> BI,ILU[NG&ZONING—473-7357 <br /> ASSESS[N G <br />