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�= � C���' o� O��I�TO <br /> p,�� Post Office Box 66•Crystal Bay,Minnesota 5a323•Muaicipal Offices <br /> ! <br /> � - • s <br /> 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 confidential inr"ormation. <br /> you are notified ,that: <br /> 1. The information you furnish will be used tb determine your <br /> aualification for the permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> tne City deny the permit or license. <br /> 3. The inforination may be snared with oth=�r e scthe permit or <br /> f ederal agencies to the extent necessary to p <br /> ?icense. <br /> a. If your requested perntit or license requires Councii ac�io% <br /> to approve, some information may become public. <br /> S . You have certain rights under M.S. 13.04 to review grivate <br /> data on yourself. <br /> 6, Your full name is required to process this application or <br /> permit. <br /> ��/ <br /> First <br /> Middle Last <br /> _�'.��" � �!�'�o �/�/ ,��'/� — <br /> Address <br /> /. �.., _ - �,t/ ,5�3�/ <br /> City <br /> State Z1p <br /> �T/- 7�3 Z <br /> Phone <br /> I underst d my rights as stated above. <br /> Sign t re ' • <br /> BUILD[NG&ZO`rING—473-7357 • ADMINISTRATION&FINANCE—473-7358 <br /> • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />