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�► <br /> � � ��"��"�� �R�I�TO <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 sub er�t or <br /> data", we would like to inform you th of itsrdee artment r may require <br /> licease from the City of Orono or any P <br /> you to furnish certain private or confidential information. <br /> You are notified that: - <br /> l. The infor f�t1�heYp�t or li ensebrequested. determine your <br /> qualification <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, s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> I.icense. <br /> 4. If your requested permit or Iicease requires Councii ac�ion <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 ful.l name is required to procoss this appl.ication or <br /> pezznit. <br /> J�FF!{Fy E'Dw,W �uTslfg�L <br /> First <br /> Middle Last <br /> I a�l f}R+�a� sr <br /> Address <br /> rono `�-'� �s 3y/ <br /> City State Zip <br /> �y�/-967G _ <br /> Phone <br /> I understand my rights as stated above. <br /> C�y�'�tK.D <br /> Sig t re � ' � � <br /> BUILDING&ZONING-473 7357 • ADMINISTRATION&FINANCE-�73 7358 <br /> • PQBLIC WORKS-473 7359 <br /> qSSESSING <br />