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. .- ' ' - <br /> � ,^^�,, , <br /> < ,�� �"*��� . <br /> � ���' °`_ ,� <br /> : CIT'�' of OR�lvO <br /> �. <br /> �, - ., _ <br /> r t° . <br /> 1 fl; { � . 'Y� <br /> �,,���� ,�,��'' � � Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> : ,� <br /> .� �' '��' �� • ' <br /> li V �f ; <br /> � _ �, ,� • On the North Shore of Lake Minnetonka <br /> DATA PRNACY 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 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 /> 4. If your requested permit or Iicense requires Counci3. action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review privat� <br /> data on yourself. <br /> 6. Yaur full name is required to process this applicatioa or <br /> permit. <br /> �ft Orn f�� � 1'L � G�/-�/�U-� �✓-'r��:Z/�,� _ <br /> First Middle Last <br /> %�i� � ✓.�/�Ul.cJnJ 1U'� <br /> Address <br /> C�JRv��y� l�� �"�3�1i <br /> City State Zip <br /> � ��� y� s � <br /> Phone <br /> I understand my rights as stated above. <br /> /�r� , �� <br /> � / <br /> � / /'� �_ � �' <br /> Signature � <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />