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>�� <br /> ';� �..-�.:.-- . <br /> � �.-�=.°�: ���� �� ��►�i�� <br /> -.�� <br /> �� <br /> �� - Yost Office Box 6fi•Crystal Bay, Minnesota 5�323•Municipal Offices <br /> i <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 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 wil.l 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 Iicense. <br /> 3. The information may be shared with other local , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Councii ac��or. <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 /> 6. Your full name is reguired to process this application or <br /> permit. <br /> ` f E y�C�ll �(�Z c' L �� ✓ "��C r1�:-i�-..Cc C( — <br /> First Middle Last � <br /> � �' , <br /> c� 7 G1 �1 �_ Cl �C�`� t�"�— - I�S - <br /> Address <br /> l..ti' Ct..- z c��r-. /l�1 /�� . � �J�Ct ( <br /> City State Zip <br /> y �� - �a��: <br /> Phone <br /> I understand my rights as stated above. <br /> � <br /> � �_ � (�� _ <br /> Signature <br /> BUILDING& ZONING—473-7357 • �DMINISTRATION&FINANCE —473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />