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_ � <br /> �+I'�"I'� Of � �N� <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipai Offices <br /> 0 <br /> • _ � � On the Nor�th 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 like to inform you that your request for a permit or <br /> 3.icense 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, 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 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 th�is applica ion or <br /> permit. <br /> � ��. � � <br /> 1 �A 9 � ��-(/� �i <br /> First Middle Last CI `j"'D r I <br /> � <br /> �Z3'� '�.�,� � � <br /> Address ���� � <br /> On,`,� f 5 �M,"� <br /> City State Zip <br /> � �--� �� � b <br /> Phone <br /> I understand my rights as stated above. <br /> � , f� � <br /> ''� <br /> Signa re • � <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 ,, <br /> ASSESSING <br />