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.. , .�,,,,�a <br /> � ��'°c �� „ry'�., '� <br /> '"�1� ��, <br /> i� �' '� `'1 <br /> � CI'�Y of �R��T� <br /> ;� ��-��- � _� <br /> � , � Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> �� • <br /> s - � i�; '�;� On th,e North. Shore of Lake Minnetonka <br /> DATA PRNACY 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 /> l. 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 Iicense. <br /> 3. The information may be shared with other iocal, state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Zicense requires Counci�. action <br /> to approve, some information may become pub3ic. <br /> 5. You have certain rights under M.S. 13.04 to review pri�at� <br /> data on yourself. <br /> 6. Yc,ur full name is required to process this applicatian or <br /> permit. <br /> /� /� /? ��� c �- / � , <br /> l/ ! /' ��(��7 FJ� f l /\-C-C-� L,� /�' �-- <br /> First Middle Last <br /> � —�� '' <br /> /���� ���.��-t'f� ���'�,� ��C�t� _ <br /> Address <br /> ��'t7��1�'-'��l �/l?�/�� � _����� <br /> City State Zip' <br /> / � <br /> �/ - �� � � <br /> Phone <br /> I understand my righ s as stated above. <br /> ��, �. ��� %'� <br /> / ����C�����"��-1 �'-� ,����C <br /> Signa re ` <br /> BUILDING&ZONING-473-7357 • ADMINISTRATION&FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />