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� � <br /> � � <br /> '�,�,.�-�z�'�:.��,.�. �`= <br /> ��� ��-�.-�-- ;;, <br /> ��� t �� I'�'�' �� ���NO <br /> r � <br /> ��+ _ <br /> �...: �.�-��.�: <br /> �� ���d�. <br /> �`��.: Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> =s�:__.. <br /> -:�#,-'ry' <br /> ��;<; <br /> 4 a'�t�r� <br /> � _ � 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 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 wi�l be used to determine your <br /> qual.ification 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 Iicense. <br /> 3. The information may be shared with other Iocal , s�ate or <br /> f ederal agencies to the extent necessary to process the permit or <br /> I.icense. <br /> 4. If your requested permit or Iicense requires Councii. ac�ior. <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 yoursel.f. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> y � � - J �, <br /> First / Middle Last <br /> � ' <br /> -� (� ,�r<� <br /> ...� - <br /> Address <br /> ���i�`2 �.� .1.�,�s�/,T " / '���/ <br /> City State Zip <br /> 1������ <br /> Phone <br /> ►.� <br /> I un r and my rights as stated above. � <br /> � ' <br /> � - � ` �e��� �.�� �'�� �� ��G� <br /> S re ' ���Lr,,�4 <br /> BUILDING&ZONING—473-7357 • ADM[NISTRATION&FINANCE—373-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />