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� <br /> , � �,���,,��r -� <br /> , ��-�S`�VY 1� <br /> 7 ayA ,':� <br /> � r3�YK � -� ��'�'`�' �f O�i►��TO <br /> q��,���y,�, ,� <br /> Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> � ,: ,� �., <br /> ';}�1 ..< <br /> � r'���5.X�^5'r�r,rx <br /> �� �',� "��� �� On the North Shore of Lake Minnetonka <br /> :��'�-.a,.�.:�. <br /> �.�.:,_.. .��.:.��W- <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 /> Iicense 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 wiZl be used to determine your <br /> qualification for the permit or license reques�ed. <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 snared with other 3ocay , 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 Councii act�or. <br /> to approve, some information may become pub3ic. <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 �o process this application or <br /> permit. <br /> J ���. � CO��.� <br /> First Middle Last <br /> ��,� �� �� • � ' <br /> 1 V�dl Y1� N,�'� � ' G� �,� ����� <br /> � <br /> City State Zip <br /> ��1 � -- tlD2 <br /> Phone ' �.� �� ��� ,�� <br /> ���/ _ �- ��i S �i'�,� z � � �. <br /> I understand m� rights as stated ab����� � <br /> ��-��„- �t� -� t��1.3 <br /> � � � <br /> �/�/'st-�-r-- <br /> Signatu <br /> BUILDING&ZONING— 473-7357 • ADMINISTRATION& FINANCE— �73-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />