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,, , " • <br /> � � <br /> �"a�x „,��� .x..v- g <br /> 3�i rF ����3,,y,y,: �,'ti'r`'S4 <br /> ,s -�► ,Fid ,3� <br /> �` � �` (i I'1�Y O� URO1�T0 <br /> ��r�;. �7�1 q;�*�^�; <br /> f�. .. Ii.;r �k� ; <br /> Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> • <br /> s ' • s 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 /> 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 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 I.ocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> 3icense. <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 priva�e <br /> data on yourself. <br /> 6. Your ful.I name is required to process this appl.ication or <br /> permit. <br /> ;�` - . , � " / "�, �, <br /> First Middle Last <br /> - / � �` <br /> Address <br /> City State Zip <br /> Phone <br /> I understand my rights as stated above. <br /> � <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FIN.atiCE—473-7358 • PUBLiC WORKS—473-7359 <br /> ASSESS[NG <br />