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� <br /> � ���� <br /> r- CI'��' O� O <br /> L C�i Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> � <br /> s _ � o 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 confidentia3. 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 local , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or 3.icense requires Councii ac��o% <br /> to approve, some information may become publ.ic. <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 app3-ication or <br /> permit. <br /> First <br /> Middle Last <br /> Address <br /> City State Zip <br /> Phone <br /> I understand my rights as stated above. <br /> 2��"� <br /> Signature � � <br /> BUiLD[NG&ZONING—473-7357 <br /> • ADMINISTRATION&FINANCE --373-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />