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�� �- ���'�.' o� ����"� <br /> - . Post Office Box 66•Crystal Bay,Minnesota 5��•M�ap��� <br /> ►�■ <br /> � <br /> . • - o •� <br /> On the North Shore o�Lake Minnetonka _ <br /> DATA PRNAC�' AD�SORY <br /> In accordance with M.S. 13. 04 , Subd. 2, "Rights of subjects of <br /> � we would like to inform you tnat your request for a permit or <br /> c,ata", of its departments may require <br /> 7=cense from the City o= Orono or any �n=Q�ation. <br /> vou to furnish certain Private or confidential <br /> vou are notified tnat: <br /> 1. The information you furnish will be used `o determine your <br /> aualification for the perni.t or license reauested. <br /> 2. you may resuse to supply data, but resusal may require that <br /> tne C�.ty deny <br /> the oermit or license. <br /> be snared witn ot�er I-ocal , s�a�e or <br /> 3. The information may o rocess the pe'-�i�. oi <br /> f ederal agencies to the extent nec..ssary to p <br /> �.icense. <br /> yod pe,-mit or iicense requires Councii ac��or. <br /> �. if vour reeues�_ become public. <br /> }o aporove, some iniornation may <br /> 5 , You have certain rights under M.S. 13.Oa to review griva�e <br /> data on yourself. <br /> 6 , Your fu1l. name is recuired to proc�ss this application or <br /> �e�it. <br /> � /�--Qti. c7 <br /> C'1,1�2�� L Z S L <br /> First riiddle <br /> �, � 5 �� �-� � 0�'L <br /> Address � <br /> f�2� � j'l'✓1^� 5 � �/ �- <br /> City <br /> ' fi State Zip <br /> C,�i - j�rC� <br /> Phane <br /> I understand my rights as stated above. <br /> � _�_� <br /> �-. <br /> ,�- . . <br /> Si riature � <br /> i <br /> 3UILD[NG&ZONING-473-7357 � ADMINISTRATION&FiNANCE-473-7358 <br /> • PUBLIC WORKS-473-7359 <br /> ASSE551N G <br />