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, , .,:r:a�-Se ' • <br /> A'. <br /> �y��;��Y <br /> ypd�+ <br /> � Y��M�° ���Y�JP <br /> � �' '�.. !°7lFS, - <br /> . ��L �=��� � ��'�"°� O� O���T� <br /> � � <br /> ������������ <br /> „.;�� �.:;;�� ,,. <br /> "� `''' ' Post Office Box 66•Crystal Bay, Minnesota 55323•biunicipal Offices <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 like to inform you that your request for a permit or <br /> license f rom 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 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 local , s`ate or <br /> federal agencies to the extent necessary to process the permit ar <br /> Iicense. <br /> 4. If your requested permit or I.icense requires Council. act�on <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�e <br /> data on yourself. <br /> 6. Your ful.I name is required to process this application or <br /> permit. <br /> � <br /> �'l �/� � v� � ;�ce���� r� �rS D�� <br /> First Midd.Ie Last _ <br /> � � � 3 G�� �r��y �� -� <br /> Address <br /> �D!i Fi d / ! � ��`3 � � <br /> City State Zip <br /> �� �' ��D �� <br /> Phone <br /> I understand my rights as stated above. <br /> 5ignature <br /> BUILDING&ZONING—473-7357 � ADMiNISTRATION&FINANCE —473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />