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� <br /> � �Y �I <br /> ��� ��-� �I'�7�' o� �R�NO <br /> � <br /> :��'-F� '� <br /> `�=,. <br /> a "�= Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> - �� <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 /> license 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 wi11. 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 local , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Councii ac��or. <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your ful.l name is required to procass this application or <br /> permit. <br /> �a �� <br /> First Middle Last <br /> �-�o !� C"`L SCo �� ��� <br /> Address " <br /> ( i� �� <br /> City State Zip <br /> `) 1 <br /> Phon <br /> I understand my rights as stated above. <br /> . �iV t�( /�--'��"_ <br /> Signature <br /> BUILDING&ZONING—473•7357 • ADMINISTRATION&FINANCE—d73-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />