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..&�;�r <br /> a� <br /> ^,�. �:�,� <br /> }��� � � <br /> =�+`:,"• � � <br /> CI'��' of O��l�T <br /> . Post Office Box 66•Crystal Bay,Minnesota 55323•Muaicipal Offices <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 subjects of <br /> data", we would like to inform you that your request for a permit or <br /> license f rom 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 Iocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> 3.icense. <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�e <br /> data on yourself. <br /> E. Your full name is required to process this application or <br /> permit. <br /> O i='��d' � ��►u(S ,�C ���z�'T�'2 <br /> First Middle Last <br /> �`l rJ� � 4-��A,C'�u r r�r(� '�c! <br /> Address <br /> �� � � � � <br /> 11(`v 1�'i� �5 ...� l� <br /> City State Zlp <br /> �7r - c� 4_�� l �y.� � ���� ,� ��t,,��:It) <br /> Phone " <br /> I understand my rights as s ted above. <br /> �� <br /> , � ��� � C . <br /> Signature <br /> BUILDING&ZONING-473-7357 • ADMINISTRATION�FINANCE-473-7358 <br /> • PUBLIC WORKS -473•7359 <br /> ASSESSING <br />