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; . <br /> � <br /> ��'�'�' O� �R�I�T� <br /> 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 /> 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 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 shared with other Iocal , 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 Council action <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 required to process this application or <br /> permit. <br /> � rs� �2��i�,( �U <br /> First Middle ast - <br /> ��oo C'AS�o ,�r ��i�. <br /> Address <br /> �,�� �� , _s�39/ <br /> City State Zip <br /> ���z) ��/- �s'9d <br /> Phone <br /> I understand my rights as stated above. <br /> G%�'Y� / ., i <br /> Signature . <br /> �,>>`,�) �,,� ///�� <br /> BU[LDING&ZONING—473-7357 �• ADMINISTRATION&FINANCE —473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />