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> <br /> �� # � ,� <br /> �� �� �, � <br /> i <br /> n� g��� �t <br /> �I'I'Y O� �R(�N� <br /> u � ,.f Ky�a " >�;� <br /> r �.,r <br /> : _ ��!_ <br /> 1� .::.� <br /> ��-�-Y'`' �'i ` `� �'°`'� 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 /> I.icense 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 Iicense. <br /> 3. The information may be shared with other Iocal , 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 privat� <br /> data on yourself. <br /> 6. Your full name is required to process this applicatian or <br /> permit. <br /> 'l�`2k�rJ`e-� (�!�i�6t�-`Q-S �.�OwkJ <br /> First Middle Last <br /> Z(� CP S� C04 3� F��� � <br /> Address <br /> GJ✓�-�Z.!�-�`1't� 1''�'.,✓ 'S� '�� � <br /> City State Zip <br /> '-C� C�--��Uc� <br /> P:�one <br /> I understand my rights as stated above. <br /> Signature <br /> BUILDIVG&ZOVIVG-473-7357 • AD'.1tINISTRATION&FItiANCE-473-7358 • PUBLIC WORKS -473-7359 <br /> ASSESSING <br />