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�c , . <br /> .� ,;<. , <br /> £�������r <br /> �����`� RONO <br /> }� �I'TY of O <br /> �.,:v::�� <br /> ;:}� <br /> ':� . Minnesota 55323•Municipal Offices <br /> Post Office Box 66 Crystal Bay, <br /> ! <br /> � _ � o On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04 , Subd. 2, "Rights of sub eerc�t� o�� <br /> data", we wou3.d like to inform you that your request for a p <br /> Iicense 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 /> l. The information you furnish will 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 license. <br /> 3. The information may be shared with oth��r e scthe permit or <br /> federal agencies to the extent necessary to p <br /> license. <br /> 4. If your requested permit or I.icense requires Councii. ac�ior. <br /> to approve, some information may become publ.ic. <br /> 5. You have certain rights under M.S. 13.04 to review priva�e <br /> data on yourself. <br /> 6. Your full name is required to proc�ss this application or <br /> permit. <br /> 5co-r-r R /�'lA(��sTN <br /> First <br /> Middle Last <br /> _]�(� 1'�3 0 �(Lo W N ,`^'` <br /> Address <br /> J � S3"`3 S� <br /> City State Zip <br /> y� 3 �s�ZF� <br /> Phone <br /> I understand my rights as stated above. <br /> — � �� •�j�l�' �✓.��/ i: � <br /> �' � � <br /> � Signa ure <br /> J <br /> BUILDING&ZONING—473•7357 • ADM[NISTRATION&FINANCE—473-7358 <br /> • PUBLIC WORKS—473-7359 <br /> ASSESSIN G <br />