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r�' . <br /> 5g <br /> ,�• � ��� <br /> � � `� � <br /> ` C ITY of ORONO <br /> � � �.�s :. <br /> ,� ., � T _ :� <br /> t ' �S ; � <br /> � . <br /> � . Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> 0 <br /> ';;?�,•�;;:.:;°; <br /> s ' o �=�� 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 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 Iicense. <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 Council action <br /> to approve, some information may become publ.ic. <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 application or <br /> permit. <br /> ' ' � �� � �e <br /> � � <br /> FirsT7 Middle Last <br /> 1 � 97� d� r � � "� �I �� D ' <br /> Address <br /> ��,zw�,� �„ �v s �� � 1 <br /> City State Zip <br /> `� 7 � � �� � � � , <br /> Phone <br /> I understand my rights as stated above. <br /> � -- � - I-� <br /> Signature <br /> BUILDING&ZOMNG—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBL[C WORKS —473-7359 <br /> ASSESSING <br />