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...'�N:� 'L�^'yr:� <br /> ��n?�.'+j. <br /> �f �c. � <br /> w �l� Ci��� O� ����� <br /> •� <br /> '�' Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Officea <br /> • <br /> � � - � �, On the North Shore of Lake Minnetonka <br /> DATA PRNACY 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 Iicense requested. <br /> 2. You may refuse to supply data, but refusal may reguire that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other iocal , 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 Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�� <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> � i c/!//3�l� � ��i�A� <br /> First Middle Last <br /> �� .L��x ��y <br /> Address <br /> ��i.���c �,�,� �,/�,�.� Ss`-3 S"� <br /> City — State Zip <br /> �l'7�- o��s3 � . <br /> Phone <br /> I understand my rights as stated above. <br /> , <br /> . <br /> Signatu e <br /> BUILD[NG&ZONING—473-7357 • ADM1N[STRATIOIV 8c FINAIVCE—473•7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />