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. ' /�����: . <br /> • o`�;,:� ,k � �-."r � . . �. � � � - � � • � . <br /> � � �4 � 4�' . . " � ����� <br /> °�ta� ' �_� ���s� �'i�'�'�' o <br /> ��-�- � � . <br /> �-"� � Post Of ce Box 66•Crystal Bay.Minnesota 55323•Municipal 4ffices <br /> E � <br /> . � .�). .� ,' . . <br /> �:� � _ A ��n On the North Shore of Lake Minnetonka <br /> � � DATA PRIVACY AD SORY � <br /> S. 13 04, Su d. 2. "Rights of subjects of <br /> In accordance with M. • <br /> data", we would like to inform you tha your request for a p r qu1re <br /> I.icense from the City of Orono or any o its departments may <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish w 11 be used to determine your <br /> qualification for the permit or lic nse 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 �hn�c s yhto processcthe permit� or <br /> federal agencies to the exten <br /> license. <br /> 4, If your requested permit or Iicense requires Councii action <br /> to approve, some information may be ome public. , <br /> �. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> � Your full name is required to rocess th�is applicata.on c!r <br /> , . � . <br /> _ ' �1 ?'mit. � } <br /> , 1 <br /> �1���� � �� W�U � <br /> Middle . Last <br /> F'�n1Av(�� NIA.N ONE tl�. <br /> 1 � ���� �. L t <br /> Address <br /> l��ToN�� � �� <br /> City - State Zip <br /> '�-4� • q 0�� <br /> Phone <br /> I understand my rights as stated ab ve. ' . �. <br /> � Signature <br /> _ � � _ -- _.. - -- - ---- _ _ -_ -_ . _ ___ . <br /> ' , . <br /> i • ADMINISTRATION&FINAN E--i73•7358 • PUBLIC H'ORKS—473-7359, <br /> [ lILDING'&ZONING—473-7357 <br /> ASSESSING <br />