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..• <br /> M <br /> �I'I'Y O� O�O�TO <br /> ;;�� � * <br /> �+� � �;� <br /> � �r��"�'z� F. : <br /> .y� !x .���,E <br /> � y,r��, <br /> _ , c� �krw:� Post Office Box 66•Crystal Bay, Minnesota�a323•Municipal Offices <br /> sp„ ,��:?�e;; <br /> s�, � , <br /> • <br /> �4 � _ � 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 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 infor.nation. <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 license. <br /> 3. The information may be shared with oth=�r �sscthe p rmit or <br /> federal agencies to the extent necessary to p <br /> license. <br /> 4. If your requested permit or Iicense requires Councii action <br /> to approve, some information may become public. <br /> 5, You have certain rights under M.S. 13.04 to review priva�� <br /> data on yourself. <br /> 6 . Your full name is required to process this applicatica or <br /> permit. <br /> ��jt��V`� 1" `t.��C � o��t 0� <br /> First <br /> Middle Last <br /> ,� g�y �G��a �'o;.�t- ��� <br /> Address <br /> �Ja,��-t_"� �M ti, �� ��� � <br /> City� State Zip <br /> �f-7� - � ��� <br /> P:�one <br /> I understand my rights as stated above. <br /> �-- <br /> Signatur <br /> • ADMINISTRATION&FINANCE —473-7358 • PUBLIC WORKS —473-73�9 <br /> BUILDING&ZONING— 473-7357 , <br /> ASSESSI�IG <br />