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1 <br /> � ' -awe� <br /> . �ssur�,.v-=� <br /> ` �.�..�.�+�i�'c�_.. 3 <br /> • _i��si-!,' . jI��'"�� <br /> :...��31���4V�a.Pt.<4 <br /> ya�! �Y <br /> ` �����.� ��r�, � ��, ���1\ � <br /> �^4"�"y�'��J Post Office Box 66•Crystai Bay, Niinnesota 55323•iYlurucipal CiiTices <br /> • <br /> �_:�- � '• �n the North Shore of Lake Mirnetonka <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 /> Iicense 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 Iicense 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 other Iocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> a. If your reauested pe�-mit or Iicense requires Council actio*� <br /> to approve, some information may become public. <br /> 5. You have certain rights under ri:5. 13.04 to review prica�� <br /> data on yourseif. <br /> 6. Your fuly aa::e is r��7�i�e� '�^ P'-'��A�S tnis applicaLion or <br /> permit. <br /> �ri�t�� l-��lm �`��.�m _ <br /> , .� ��4 .�}1 a T<d S i <br /> L'1 1 J l. <br /> !�•�t; .'S ���ZG�'1 �C%� <br /> Address <br /> �,�'l� - i�? �''I!'� ���1 <br /> City State Zip <br /> �7 3- ����ti� <br /> Phone <br /> I understand my rights as stated above. <br /> '� <br /> ZG� /�����'n-� <br /> Signature <br /> BUILDING&ZONING -473-7357 • ADM[NISTRATION&FINANCE -473-7358 • PUBLIC WORKS -473-7359 <br /> ASSESSIN G <br />