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�, � <br /> ��� y#f� �iF��" <br /> u.i Y.� <br /> 2; j � ' '« <br /> ^. � �-- b �� C ITY of ORON(� <br /> . _� ""-,�. r,�~�`, <br /> Post O�ce Box 66•Crystal Bay, Minnesota 5a323•Municipal Offices <br /> � <br /> � _ � � Orc 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 yau 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 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 license requires Council actio*� <br /> to approve, some information may become publ.ic. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�e <br /> data on yourself. <br /> 6. Your full name is required to process this applicaticn or <br /> permit. �' ._ <br /> � � � r, � �� C �� <br /> � kr� �''� � � ��� � c� � �) . <br /> i st Middle � ast <br /> � �� Z I,- , �� , � -,,.�, �� <br /> Address � <br /> � � ; � � � (1� �-- � �� Z. (,� <br /> � �� <br /> City State Zip <br /> ���� �� ?��� <br /> Phone <br /> � <br /> I understand my r�,ghts as stated above. <br /> � <br /> ��,. <br /> Signature � <br /> BUILDING&ZO`lING—473-7357 <br /> • AD!�tINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />