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• ' � - <br /> � ' <br /> '�''""���'{,_� • <br /> ����� ���� O� ����0 <br /> . Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> ' <br /> • - e � On the Narth 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 /> 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 license 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 local , state or <br /> federal agencies to the extant necessary to process the permit or <br /> license. <br /> 4. If your requested permit or I.icense 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�ate <br /> data on yourself. <br /> 6. Your full name is required to process this applicatian or <br /> permit. <br /> �c�f�� l� � Q �(� � <br /> First Middle Last <br /> �� 1 a�? C 22 � �'o �� �o�i <br /> Address <br /> ����"T�L ��� �� �� � � <br /> City State Zlp <br /> �� � ��� ��J <br /> Phone � <br /> I underst d my righ s as st ed above. <br /> . �- <br /> Signature <br /> BUILDING&ZONING-473•7357 • AD�tINISTRATION&FINANCE-473-7358 • PUBLIC WORKS -473-7359 <br /> ASSESSIN G - <br />