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. • � . <br /> ��;G� <br /> �� � <br /> 4 CITY of ORONO <br /> � <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 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 Iicense. <br /> 3. The information may be shared with other Iocal , state or <br /> federa.I agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii. action <br /> to approve, some information may become public. <br /> 5. You have certain rights ander M.S. 13.04 to review priva�� <br /> data on yourself. <br /> 6. Your ful.l name is required to process this applicatian or <br /> permit. <br /> ��-��J '�J�1°2w� �Ar� �R� <br /> First Middle Last <br /> a��, �cti �� t� <br /> Address <br /> ��,;,.,.�� �Y�v� >;��'`I° -- <br /> City State Zip <br /> ��i��,- -����1' <br /> Phone <br /> I understand my rights as stated above. <br /> �� � <br /> ����.. �.,t;'4'0�2.�j,.���� <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATIOIY&F[NANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESS[NG <br />