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CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Officea <br /> • <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 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 /> l. 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 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 3icense requires Councii action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 �o review prica�� <br /> data on yourself. <br /> 6. Yaur full name is required to process this applicatian or <br /> permit. <br /> ��1�C�e�t ��',L� s ir,�i�ek � <br /> ;�; ��,l 3��+'�5 t=c�S% — <br /> First Middle Last <br /> �9y� c;�s Gv �i �� <br /> Address <br /> �'�G�N C /`-l�V S-S"3 �/ <br /> City State Zlp <br /> ��i- il '7z <br /> Phone <br /> I understand my rights as �stated bove. <br /> /.� � ��' � � L -� <br /> �6ignatur <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />