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'� <br /> ��j� `���j� CITY of ORONO <br /> � �; <br /> 3�>c� <br /> � <br /> ;K� � �`:s,+<: <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> � - � � 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 /> 1. The information you furnish will be used to determine your <br /> qualification for the permit or license reguested. <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 Zocal, state or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <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 priva�E <br /> data on yourself. <br /> E. Your full name is required to process this application or <br /> permit. <br /> � <br /> a ' . <br /> ���;'( �YVWIf��,a�rt�d-�— <br /> irst Middle Last <br /> /��j l 1�,.��_r��cti� �) - �— <br /> Address <br /> `�'i'� @�ti1-� .�C��'v`✓l ' �.�.a � � <br /> City State Zip <br /> y �� - ��i/ <br /> Phone <br /> I understand my rights as stated above. <br /> `yi <br /> �. 1�\„�.-¢�� � ' ��r l.n.'r`1.�/��'r�-£,,,,, <br /> Signature • <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBL[C WORKS—473-7359 <br /> ASSESSING <br />