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�A�,�:� �. <br /> =��`:.. Ci��� O� ���1�� <br /> . <br /> `'� � ' �� Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> r <br /> i <br /> � � - � s> 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 /> 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 /> 1. The. information you furnish wiil be used to determine your <br /> qualification for the permit or license requested. <br /> 2. You may refuse to supply data, but refusaZ may require that <br /> the City deny the permit or I.icense. <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 Iicense requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�� <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> L� (�/? T�S �' i��`I-�'�-�-� f�`/?G-r-,�-s <br /> First Middle Last <br /> %�/l� /.��� /�(//� ✓'/<- /t /�- <br /> Address <br /> ,�,�'' /t��/vU /?�1 �✓ S S� j/ <br /> City State Zip <br /> � <br /> y`;,/ - ol �"�`� . <br /> Phone <br /> I understand my rights as stated above. <br /> �� � <br /> ,�.- '� � ;' � <br /> Si ature <br /> +"� 'LDtNG&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 � PUBLIC WORKS—473-7359 <br /> �SSESSING <br />