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iii <br /> � � <br /> ` CITY of ORONO <br /> ,'�""n1},+i� a+ei"tI .S . <br /> � .y � '� <br /> 9��?,�y.� �� �, <br /> �"�� .� * ���i Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> 4 � �_ �`� <br /> �da <br /> `'�`'���� On the North Shore of Lake Minnetonka <br /> �, � s <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 /> Iicense 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 /> l. The information you furnish wil..I 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 /> federa3. agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Council. action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�at� <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> '��1 � � 1 %C i +� ��' � ��� l�y-�;,�/� •_%/� <br /> First Middle Last <br /> ��<�'�`� ��'CiV�I`' �,�=' �c�cJ/!-�. <br /> Address <br /> �''��; b�!�y:/� T`� ��'7 >L i,�} .�j�� <br /> City � State Zip <br /> �� � � y// `1 . <br /> Phone <br /> I understand my rights as stated above. <br /> ; � � <br /> %/� �.?v/' v `7 / ' '" :'7,�� ji / <br /> .(�v <br /> Si nature � <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />