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� i <br /> �� <br /> �����.�»� <br /> `n3.. �. �1��" ';:, <br /> � %� <br /> ����� � �1�.� �i��� O� ����� <br /> �s �� �. ?,..� <br /> � ��� ;�� <br /> �:�. � <br /> G ` -�=°-�ryy Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> y `:'.4 <br /> • �e �� <br /> o ' e o �� On the North Shore of Lake Minnetonka <br /> DATA PRNACY 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 information. <br /> You are notified that: <br /> l. 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 Iocal , s�ate 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 act�or. <br /> to approve, some information may become public. <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 proc�ss this application or <br /> permit. <br /> ,��yv' Qs �o�;v� d�r` , S <br /> First Middle Last <br /> c� ` � �.o�c� <br /> Cu.s �.-0 9 r v�, <br /> Address <br /> 1�� � �� 5�3 � 1 — <br /> City State Z1p <br /> 4 -� i g c�Zz <br /> Phone <br /> I understand my rights as stated above. <br /> � ^ <br /> Signatu <br /> � <br /> BUILDINC&ZONING—473-7357 <br /> • ADMINISTRATION&FINANCE — �73-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />