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. <br /> . �, <br /> ,;:�;: <br /> � ��, ��� �; �� <br /> � � �� .��: 3u C I'�3�' Of ���i�T� <br /> � �� �-� Post O�ce Box 66•Crystal Bay,Minnesota 5a323•Municipal Offices <br /> « : � <br /> '+ .��. s����, r' <br /> � s -�"� A,` On the North 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 3ike 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 wi3. 1 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 Councii action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�� <br /> data on yourself. <br /> 6. Your full name is required to process this applicatian or <br /> permit. <br /> �J��l��V�� �/�� �l�f��"�(.��� <br /> First Middle Last <br /> 1' f t� �I���t.��f� 1� �'��• <br /> dress <br /> � , !�.v ���`� <br /> City State Zip <br /> ��� - ��:��� I <br /> Phone <br /> I understand my rights as stated above. <br /> _ � � � , <br /> Signature <br /> � <br /> BUILDING&ZONING-473-7357 • AD!11L'�IISTRATION&FIVANCE -473-7358 • P[JBLIC WORKS-473-7359 <br /> ASSESSIN G <br />