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� '�:: <br /> �,,e ,R�-,��"�-��' � <br /> �»` >�a�� <br /> w � ¢ �h , ,��'�1'�' O� ����T� <br /> ��� _ .� <br /> a�•aU�',.�a�;f <br /> �ux;:�� <br /> "� " � ° � "y``� Post Office Box 66•Crystal Bay, Minnesota 55323•Munici al Offices <br /> ����.*��k;,. P <br /> � � � . <br /> � � - �� �;_ 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 /> 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 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 Iicense requires Councii act�or. <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to rev�ew priva�e <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> � � <br /> Yt ;t�;C'��'� �Y'�tW�� �� �S <br /> First Middle � Last . <br /> � � <br /> '�� aS _L;z� � ���!�� <br /> Address <br /> ����� <br /> ` ►��1 ��l 3� <br /> City State Zip <br /> �� � � t3 �� <br /> Phone <br /> 2 understand my rig s as te above. � <br /> . / � <br /> Sig t re � <br /> BUILDING&ZONING—473-7357 • ADMINIS ATIOIV&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />