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� <br /> a:�� �aR`� <br /> '.'�s+.... f^ -.�::�.9 <br /> f <br /> � +{ <br /> " � t' ` (iI'Y`Y Of OROI�TO <br /> A� Y, � <br /> a��"' ��;:' .` ;;� Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal�ffices <br /> • '� <br /> -,+ <br /> ` � - ,� a"����� On the North Shore of Lake Minnetonka <br /> � <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 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 shared with other iocal, state or <br /> federal agencies to the extent necessary to process the permit or <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 revi.ew pri�a�e <br /> data on yourself. <br /> 6. Yaur full name is required to process this apFlicatian or <br /> permit. <br /> ������ c_,�r a� - ,�r�_ <br /> First Middle i.ast <br /> `?� �� Z 4-� <br /> Address <br /> SF?�2� r�c� �,��►L y...�,,r-.+ sS��i4-- <br /> City State Zip <br /> �- Lf �7 �-�S 3 Z. <br /> Phone <br /> I understand my rights as stated above. <br /> /� <br /> � _ <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINiSTRATION& FINANCE—473-7358 � PUBLIC WORKS —473-7359 <br /> ASSESSING <br /> . <br />