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,`j �4 <br /> y ��� �� CITY of ORONO <br /> _ <br /> � <br /> ��-° e � Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> 0 �;�� <br /> s - � �� On the North Slzore 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 /> Iicense 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 supply data, but refusal may require that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with other local , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or 3icense requires Council action <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 /> ..-r—-- <br /> ����-��;�- / �Jc���l--� ��cic�� <br /> First Middle Last <br /> �,�c��� ,fl �������� � �k3/C��� � <br /> Address - <br /> /'����r ���l /�'/�( ( �5`:.�(���� <br /> City State Zip <br /> � 7'7- � G-�(-� <br /> ,.J' i � ,.:�� <br /> Phone <br /> I understand �y righ s s stated above. <br /> � <br /> / i <br /> � � � �. <br /> Sig ature <br /> BUILDING&ZONiNG—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />