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� �• <br /> �.� ,"`;�6�-� <br /> �.,.,r;�.�:� a�x{ ',� <br /> �J�}� �'�* h E"�� <br /> ��• v�� � <br /> ��'��_ � +��,:� C I'TI' Of UR�leTO <br /> ��:r .� `� c�. - <br /> -�;,,,�.� ,r Y e. <br /> uJfK��� , <br /> ��.5�'{t'.�. <br /> ;_�- � Post Office Box 66•Crystal Bay,Minnesota 5a323•Municipal Offices <br /> 'a"_�;"f .'. 9 �. <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 Iike to inform you that your request for a permit or <br /> I.icense 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 Iicense 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 /> license. <br /> 4. If your requested permit or Iicense requires Councii action <br /> to approve, some inf ormation may become public. <br /> 5, You have certain rights under M.S. 13.04 to review pri�a�� <br /> data on yourself. <br /> 6, Yaur full name is reguired to process this applica�ian or <br /> permit. <br /> j)'Jlc� �� � ��� �-���- �l� /�R� ��I. <br /> First <br /> Middle Last <br /> 3`� +� � ���l S� r �)`� ►��-��_ <br /> Address <br /> a'k� 1�I�L� ��L l�11L` /Y1 � 5 � 3 S � <br /> City State Z1p <br /> ,� 7� - ! ��S <br /> Phone <br /> I understand my rights as stated above. <br /> _ ���'��. ; ��. '� , �� ��-�i� <br /> ; .� ��.� ,�'� <br /> � � � f�.�_ <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMllYISTRATTOV&FINANCE—473-7358 <br /> • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />