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, <br /> � <br /> ���` ��''+m„�5.��- <br /> ,;,= <br /> � � �i��� O� ����� <br /> �� � <br /> � <br /> "'� ` Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> 0 <br /> s . � v 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 /> l. 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 license. <br /> 3. The information may be shared with other Iocal , s�ate 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 ac��or. <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 fu.Il name is required to process this application or <br /> permit. � <br /> i , � <br /> _� � � � <br /> ,� <br /> � �",t�� . �I,t � ,_ �' i.��-;' f- � /��l;-,t--�t_,_ <br /> First Middle Last <br /> =. '�` ., � ra� - . <br /> Address <br /> _4 ,, �, � � ,-�J. � �� <br /> � � �r- �-�� '� - '"i � , _. . , : _ _ <br /> City_, ,i��' State Zip <br /> � <br /> �_. > <br /> Phone <br /> I �nderstand my right as stated above. <br /> � � �� �� <br /> ..�.� �' ---" <br /> ; �- <br /> v� Signature . <br /> BUILDING&ZONING — 473•7357 � AD�fINISTRAT10N& FIN:�NCE — 473-7358 � PUBLIC WORKS —473-7359 <br /> ASSESSING <br />