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. � <br /> ,,,� 4�,� <br /> q"�,�,;,r�� � <Ux <br /> %:x X .: ��. tiy.• <br /> � t��TK�� � � � CI�'I' o� OIE���T(� <br /> � t <br /> � �. <br /> �' �``t' ' ' � Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> r <br /> i y y�� :� %" <br /> ',. a : �y � ''�:.� 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 /> l. The information you furnish will be used to determine your <br /> qualification 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 ioca I , 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 information may become publ.ic. <br /> 5. You have certain rights under M.S. 13.04 to review priva�� <br /> data on yourself. <br /> 6. Yaur full name is required to process this apglicatian or <br /> permit. <br /> �/�,2 L��S (,�;°�L���, 1/I�i ��/'�-./L�s <br /> First Middle ' Last <br /> ���� T/�"� �a✓r� �iq,J� <br /> Address <br /> / ^ C/ �/ � , <br /> � �L� �'v W — <br /> �y S ate Zip <br /> ���- 61/ � <br /> Phone <br /> I understand my rights as stated above. <br /> '�� _ <br /> gnature <br /> BUILDING&ZONING–473-7357 • ADMINISTRATION&FINANCE–473-7358 • PUBL[C WORKS–473-7359 <br /> ASSESSING • <br />