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� � <br /> <�... _ <br /> _ � � _ <br /> -�....� " ��'�'�' o� ����T� <br /> ��� <br /> �`'� �� Post Office Box 66•Crystal Bay, Minnesota 5a323•Municipal Offices <br /> 0 <br /> = s - a g 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 /> 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 will be used to determine your <br /> aualification for the permit or Iicense requested. <br /> 2. You may refuse to supply data, but refusal may reauire that <br /> the City deny the permit or license. <br /> 3. The information may be snared with other Iocal , s�a�e or <br /> f ederal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> a. If your requested per^�it or Iicense ?'?C.Sll1?'AS Councii ac�io% <br /> to approve, some information may become pub3ic. <br /> 5. You have certain rights under M.S. 13.04 to rev�ew grivate <br /> data on yourself. <br /> 6 . Your full name is required to process this appl.ication or <br /> permit. <br /> �/`��.f �� �5. ��,•1 ni o�/� <br /> First Middle Las` <br /> o��a �i , /�- �� <br /> � �rs<<� s-� <br /> Address <br /> ���.,;yz,� ;� ,�,v �s � �I <br /> City State Zip <br /> ���'G�,�% <br /> Phone <br /> I understand my rights as stated above. <br /> ������ .�_ � <br /> Signature � <br /> k31,`ILDIVG& ZONI�G-473-7357 • AD,tiiINISTRA?ION&FIVA?10E - 473-73�3 • PUQLIC WORKS - 473-7359 <br /> ASSESS(N G <br />