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a <br /> ' - �.� <br /> ?4�s.�� _ �� , <br /> �������' �. <br /> b <br /> �-�,���3. - C�'�I' o� O�OIOT� <br /> � <br /> �-� . �� <br /> �. <br /> ���� <br /> ~��^S6 Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> 0 i =��: <br /> • - e •� � On the North Shore of Lake Minnetonka <br /> DATA PRNACY 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 Iicense 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 snared with other Ioca1 , 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 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 yourself. <br /> 6. Your full name is required to proc�ss this application or <br /> � pe�-mit. <br /> First Middle Last <br /> Address <br /> City State Zip <br /> Phone <br /> I understand my rights as stated above. <br /> Signature <br /> BUILDItiG&ZOY[NG—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />