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1 �. . <br /> _� <br /> _�1.�.:�=� � <br /> y����:�i <br /> -�y,.��... �.,�� <br /> T�� ��'�' � �� ����� <br /> 4 <br /> �`^- - Post Office Box 66•Crystai Bay, Minnesota��323•iYlunicipai Uinces <br /> • <br /> � _:a� �-�• On the �'�'arth 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 /> license from 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 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 shared with other Iocal , state or <br /> federal agencies to the extent necessary to process the pexmit or <br /> license. <br /> 4. If your requested perm�t or Iicense requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rignts under M:�. 13.04 to review pri�a�� <br /> data on yourself. <br /> 6. Your fu�l :.a::e �s -��'�==p�' '�^ Pr��P`s �nis applicaLion or <br /> permit. <br /> .,, � c Z�(G��/1 <br /> r�rs� �; �,^� e r ast <br /> S � � � <br /> Address <br /> ����nU <br /> � � �� � � <br /> City Sta e Zlp <br /> �� L�--�� � � <br /> Phone � <br /> I understand my rights as stated above. <br /> `, <br /> �-- <br /> S gnature <br /> BUILDING&ZONING—473-7357 � ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />