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'� � *� . ,. <br /> 4 � � �:� <br /> ^'°�- .- �: � <br /> a�ir <br /> n �, �. � � .',:i <br /> �� �� ; �c� �I'TY of ORON� <br /> �k�= y� <br /> _ c., .4a..Y' <br /> ��. . <br /> n � Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> • <br /> � _ � v On the North Shore of Lake Minn.etonka <br /> DATA PRNACY ADVIS�RY <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 /> Iicense f rom the City of Orono or any of its departments may require <br /> you to furnish certain private or confidentia3 information. <br /> You are notified that: <br /> 1. The information you furnish wil3. 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 snared with othT�r sscthe permit or <br /> federal agencies to the extent necessary to p <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Councii ac��o% <br /> to aporove, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> NI I C, � A-e� ���� �n � f"� !�3��-�ti��; <br /> First <br /> Middle Last <br /> �`�(� � ��'� �1 ��S ��.� �'� , <br /> Address ��� ��� <br /> i YI� �'L--� !=%:��'; r �' �^�' /�i�, ' <br /> City State Zip <br /> � <br /> ��� ' � � � � <br /> Phone <br /> I understand my rights as stated above. <br /> � �-� � '�,��-�,c��- <br /> ���)��;��r�a�-� � � <br /> Signature � <br /> BUILDING&ZONING—473-7357 • ADMINISTRATtON&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />