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_ , .1�. <br /> :,t_ <br /> 1 � � <br /> ,� � �� <br /> - :� CI'1'`.�' O� ORO <br /> 41 Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> s _ � o 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 like to inform you that your request for a permit or <br /> license f rom 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 refusa3 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 3icense 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 full name is required to procsss this application or <br /> pe?-mit. <br /> .� l� �c�L� Z � V� �-E� r-� <br /> First <br /> Middle Last <br /> �j y,� S�jti�� � � � � �- - <br /> Address <br /> � �' � z ��v-�— /�'���- S �� <br /> Cit State Zip <br /> � �� _ � s- � � <br /> Phone <br /> I understand my rights as stated above. <br /> � <br /> � �''v <br /> Signatur � . � <br /> BUILD[NG&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />