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, r <br /> "�cK't r�;y ( 4 K,'` <br /> '�4x���.- �t,,. I'�"�' o� OI$�1�T0 <br /> t�:� �� . <br /> � <br /> ������.'" ,'` Post Office Box 6&•Crystal Bay,Minnesota 55323•Municipal Offices <br /> �;� �,y.,x,�3.� ` <br /> `KF+C_.��t•�.v�t ;� <br /> b ,�- � r-g,� On the North Stzore 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 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 �ocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or become e bliclres Councii action <br /> to appro v e, some inf ormation may P <br /> 5. You have certain rights under M.S. 13.04 �o review pri�a�� <br /> data on yourself. <br /> 6, Your full name is required to process this apgl.icatian o� <br /> permi . <br /> ,e_ �� � � �, � (� �,. <br /> First Middle � Last <br /> � ' � -�- ��� <br /> -�2� �� �,`��s�� <br /> Address i � �-. <br /> �j{�L� � G� ' �/ / �� ��S / <br /> City State Zip <br /> .��j �- � � -�3 <br /> P�one <br /> I understand my rights as stated above. <br /> � 7 � <br /> `� ;' �� `\-%�,t� <br /> / ( <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />