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- <br /> . . — 4 <br /> .f.r, tio���.F <br /> �"�v�C�..;J�'Ry�`N vYi� • � <br /> \J , <br /> �����`��t � (�IT�' of OROIeT� <br /> � <br /> ,��p,�� �.�� <br /> � l L�'..� �T" .,,y,Y;� b • <br /> t�}�� �9��.4�� <br /> 3�'`� < � <br /> ���.. . � . �� s <br /> "y.�,��'��4`� Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> `r;i #�, � <br /> i�K�a����r a♦� . <br /> :_ � _ � "`"� On the North Shore of Lake Minnetonka <br /> DATA PRNAC`I 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 /> 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 /> qual.ification 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 ioca3 , 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 action <br /> to approve, some inf ormation may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�� <br /> data on yourself. <br /> 6. Yaur full name is required to process this applicatiaa or <br /> permit. <br /> ._� � � ` �\.�P, -��.s��i'� <br /> ��.sL � ���'i� i'` ���, ', � �'�" <br /> First Middle Last <br /> � -�, ^� � ,-�'� -.r �� ���� ���� �� <br /> � � � � � �-�� <br /> Address <br /> � ` -y� �._t` ,��,,� - - . <br /> City �, � State Zip <br /> � � --, <br /> �' i�� - � 1 :��. � <br /> y Phone <br /> I understand my rights as stated above. <br /> �ti�� �, �� � ` �� - <br /> Signa£ure `� <br /> BUILDING&ZONING—473-7357 <br /> • �.D!NL�IISTRATION&FItiAIVCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSIN G <br />