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� � �� <br /> - .��µ����`�. <br /> � �� '»- � ����� <br /> �_ �_.���_� CI'�`�' o <br /> *.� ��..`� <br /> zU���_��....��z <br /> ' � '"�` Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> 0 <br /> �. _ � o On the North Shore of Lake Minnetonka <br /> DATA PRNACY ADVISORY <br /> In accordance with M.S. 13.04 , Subd. Z , "Rights of subjects of <br /> data", we would like 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 /> l. � The information you furnish will be used to determine your <br /> qualification for the permit or license 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 snared with other local , e�i� or <br /> federal agencies to the extent necessary to process the p <br /> license. <br /> 4. If your requested permit or Iicense requires Councii ac��o% <br /> to approve, some infor:nation may become public. <br /> 5, You have certain rigr.ts under M.S. 13.04 to review private <br /> data on yourself. <br /> 6 , Your fuZl name is required to proc�ss this appl.ica�ion or <br /> pe�it. <br /> � s� ���� <br /> ��`�� Middle Last <br /> First <br /> S�-r 75�� � �'lN lis.%��1� �G ��- <br /> Address <br /> I � i �v/'vd f�l}-� .SS �,�L� - <br /> �City State Z1p <br /> ��� - 6ss � <br /> Phone <br /> I understand my rights as stated above. <br /> Signature � <br /> BUILDING&ZO`lING —473-7357 • ADMINISTRATION&FINANCE —�73-7358 <br /> • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />