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� __ <br /> .��...•� � <br /> , . <br /> • , <br /> �({' .�� K <br /> � .�J <br /> T.�++ : s -�'Fr; <br /> ,'�d�-�'� "�3 . <br /> :_� ��YF*��� � L* //�_� <br /> �.�1L�Y�-. ya.W.� F.--: ���� �Il �i_��� <br /> :+ �'l `� t ��'�' � <br /> r� � <br /> `';',:,�;,�,, �" ":;���'� Post O ice Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> ` -� y:,,-��;x <br /> ,t�`;R , <br /> _-�w�::_ , �'-. _ <br /> �� j _�,� ,� -> On the North Shor of Lake Minnetonka <br /> �"J DATA PRIVACY AD SORY <br /> In accordance with M.S. 13.04 , Su d. 2 , "Rights of subjects of <br /> data", we would Iike to inform you tha your request for a permit or <br /> Iicense from the City of Orono or any o its departments may require <br /> you to furnish certain private or confi ential information. <br /> You are notified that: <br /> l. The information you furnish w 3.1 be used to determine your <br /> aualification for the permit or li ense 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 share with other Iocal , s�ate or <br /> federal agencies to the extent nece sary to process the permit or <br /> license. <br /> a. Tf your requested permit or I ' cense requires Councii actior. <br /> to approve, some information may be ome 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 roc�ss this application or <br /> permit. <br /> �1a��; K�� . t�t� v��� <br /> First . <br /> Middle Last <br /> °WA�!-� 1`�1�0 N�E � lf�. 1 <br /> Address <br /> ��Tv��� �� <br /> City State Zip <br /> �-4� • �1 t�`��� <br /> Phone <br /> I understand my rights as stated ab ve. <br /> Signature <br /> BUILDING&ZONTNG-473-7357 • ADMINISTRATION&FINANC -�73-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSI;YG <br />