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. <br /> : . � ��'��i' o� ����TO <br /> «s Post Office Box 66•Crystal Bay,Minnesota 5�323•Municipal O�ffices <br /> � <br /> � _ � � 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 like to inform you that your request for a permi 1re <br /> license from the City oi Orono or any of its departments may req <br /> you to furnish certain private or confidentia3. in=ormation. <br /> You are notified that: <br /> l. The information you furnish wil.l be used to determine your <br /> aualification for the permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> tne City deny the permit or license. <br /> 3. The information may be shared with oth=�r esscthe permit or <br /> f ederal agencies to the extent necessary to p <br /> license. <br /> a. If your requested pe�-mit or Iicense requ�res Councii ac��or. <br /> to aporove, some information may become public. <br /> 5. You have certain rights under M.S. 13.Oa to rev�ew private <br /> data on yourself. <br /> 6. Your full name is recruired to proc�ss this application or <br /> � <br /> per•nit. _... ) ` �`o �x�p �i o �'s <br /> �- / ✓��� C!/�C ) <br /> �I t In CJ !U J ! ��"� � �n INl G 1n �l <br /> First <br /> Middl.e La <br /> � (,�O � � v� v�c-.�lj � Lt� '�/ � <br /> Address <br /> �� ,.v�v v 7� � /c�i� .S�>�l �{ � <br /> Ci y State Zip <br /> ,Ss 3 - l� � � <br /> Phone <br /> I understand my rights as stated above. <br /> . V 1 <br /> ignature " <br /> BU1LD[NG&ZONING-473-7357 • ADMINISTRATION&FINANCE-473-7358 <br /> • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />