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, � <br /> �_ - <br /> _ � _ - <br /> � � ���'�' �� ����'� <br /> t <br /> a Posi Office Box 66•Crystal Bay, Minnesota 5�323•'dunicipal Offices <br /> 0 <br /> : � - � g On the Nortfz Shore of Lake l�finnetanka <br /> DATA PRSVACY ADVISORY <br /> In accordance with M.S. I.3.04, Subd. 2, "Rights of subjects of <br /> data", we would like 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 confidentiaZ information. <br /> You are notified that: <br /> I. The information you furnish will be used to determine your <br /> cua�.izication for the pe?-:nit or Iicense recuested. <br /> 2. vou r,iay refuse to supp?y data, but re=usal may reQuire that <br /> the City deny the permit or I.icense. <br /> � . The inf ormation may be s'r.ared w;tn ot:�er Ioca I , s�a�e or <br /> f ederal agencies to the extent necessary to process tne pe?-mit or <br /> ?icense. <br /> a. If your requested per.:.it or Iicense _equires Councii ac��or_ <br /> to a�prove, some infor:nation may become public. <br /> 5 . You have certain rignts under ri.S. 13.0� to rev_ew private <br /> data on yourself. <br /> 6. Your full name is required to p�ocess this appZication or <br /> per•nit. <br /> �_ � , <br /> -� r ; ; <br /> I � � '� ' ,�.�(��4r�� ;'''�; !`��,, I �� i,,"1 � (��� <br /> £�irst Midd�e Las� <br /> . � ,; � � <br /> -' �_' . � ,1�, �_;�� � ��i <br /> Address <br /> 1---- <br /> t ' � <br /> ��� �+ I 1 /' �, �._ �;- � , <br /> ,-� � f�� � U.;�:�, � , ,, <br /> City State Zip <br /> , r-; ; . ._. <br /> i" ' - < � `% <br /> Phone <br /> I understand my rights as $ta�ed �bove. <br /> �, �, � j <br /> � , <br /> t � � � . <br /> �/ / _�v ' � <br /> Si na u e - � . <br /> Bl,'ILDI�'G& ZOti'1`G - 473-7357 • ADJfINlSTRATION& FIV��NCE - 4%3-73=3 • PUBLIC WORKS -473-7359 <br /> ASSESSIVG <br />