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� <br /> �- � <br /> r:�.' ��. <br /> - ���'�' �� ���1�� <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <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 like to inform you that your request for a permit or <br /> license f rom 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 wil.I 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 Iicense. <br /> 3. The information may be shared with other local , s`ate or <br /> federal. agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Councii ac�io% <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 to process this appl.ication or <br /> permit. <br /> �� � S_G��r/�Of=i1 <br /> First Middl.e Last - <br /> _3 �� y G�:S��� :� /��'� <br /> Address <br /> C'�L'�/1�/ Z./�T/S/ r'j1/�/ .��5�� // <br /> City State Zip <br /> �-f� / -- �/S-! <br /> Phone <br /> I understand my rights as stated above. <br /> �. <br /> Sig at e � � <br /> BUILDING&ZONiNG—473-7357 � ADMINISTRATION&FINANCE —473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />