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. � <br /> � <br /> c�TY o� o�aoNo <br /> Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> • <br /> � _ � � On the Nortlz 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 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 confidentia3 information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your <br /> qualification for the permit or license requested. <br /> 2. You may refuse to supply data, but refusal may reguire that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with other Iocal , s�ate 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 ac��or. <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6 . Your full name is required �o proc�ss this appZication or <br /> permit. <br /> ,�;'r,� ��r-� ��%�5����- <br /> First Middle Last <br /> /�� S ���%c�%�� ,��� � — <br /> Address <br /> C -6 �ii�/�- f�'��''� ��-���� <br /> Ci� State Zip <br /> ��%�� ���-�� <br /> Phone <br /> I understand my rights as stated above. <br /> � � � /I� <br /> � �� ` - `���Li <br /> .� �� �� <br /> Signature �� <br /> BUILDItiG&ZONING—4'13-7357 • ADMINISTRAT[ON&FINANCE —473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />