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�4 � <br /> � <br /> t, a � <br /> �: � a 4, CiITY O� �R�I�TT� <br /> r ��� r; ,�; r,: <br /> ': _ ' ' Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> �,>..''s t �� <br /> .n ,y 4 <br /> � k '��"�'�� On the North Shore of Lake Minnetonka <br /> � � � � <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 iocay , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or I.icense requires Councii act�on <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 /> 5. Your full. name is required to process this application or <br /> permit. <br /> � --—7 <br /> '��� � �rl ( tl_ � �LcF ��/ ����_ . <br /> First Middle Last <br /> `_� <br /> Z �� � �� ��I� �C'C' � ��� � �� u � - <br /> Address <br /> ��c��� � Jli �'' `=��.;��1 � <br /> City State Zip <br /> !, �� _ �-�� �i � - ����� ���"._ <br /> Phone <br /> I understand my rights as stated above. <br /> `_--� <br /> �J ) /` ��f' L/Z� <br /> Signature _� <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FIN.4NCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSIti G <br />