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4 <br />CITY <br />OF <br />ORONO <br />— ^ <br />-i <br />J <br />JJL <br />’it <br />(y <br />< <br />i A"X. <br />CITY of ORONO <br />fml Otftc9 hex M*Crr«ial B«y» SftXD* OCBcvi <br />On the North Shore <rf Lake Minnetonka <br />DATA PRIVACr ADVXSORT <br />In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br />data", we would like 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 />qualification 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 license. <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 license 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 <br />permit. <br />name is required <br />A <br />to process this application <br />/iO/ATTSi^ <br />First Middle Last <br />/hZjY) 0^/cJ£- ' • _ ■■ <br />Addrass <br />rr?/^ <br />waw uy state Zip <br />P^one <br />I underst^d my rights as stated above. <br />Sigxlature <br />• . <br />• * <br />BUILDING A ZONING - 473-7357 <br />assessing <br />administration a finance - 473-735S PUBLIC WORKS - 473-7359 <br />i