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�i, <br /> ; � � - - . <br /> �i��Y O� o���� <br /> Post Office Box 66•Crystal Bay,Minneaota 55323•Municipal Offices <br /> • <br /> � _ � e On the 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 Iike 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 Iicense reguested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or 3icense. <br /> 3. The information may be shared with other Iocal, state or <br /> f edera7. agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Council action <br /> to approve, some information may become public. <br /> 5. You have cert�in rights under M.S. 13.04 to review pri�a�e <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> � ��`-� l.._. �-►-�►J c� , <br /> First Middle Last <br /> '�� `� � �-�t�c�G,�� f�-✓� • s � <br /> Address <br /> ,����Ff�-� /y1�1/� ���-z3 <br /> City State Zlp <br /> e��- �6 <br /> Phone � <br /> I under and y rights as stated bove. <br /> i' � <br /> � <br /> Si ature <br /> BUILDING&ZONiNG-473-7357 • ADMINISTRATION&FINANCE-473-7358 • PUBLIC WORKS -473-7359 <br /> ASSESSING ' <br />