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. <br /> � ` _ . � <br /> CITY of OROl�TO <br /> Post Office Box 66•Crystal Bay,Minneaota 55323•Municipal 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 Iike 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 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, state or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�� <br /> data on yourself. <br /> E. Your full name is required to process this application or <br /> permit. <br /> �G'�t r Yci��� fH �l S/ /^c"t%''� <br /> First Middle Last <br /> c1,� ^�s o <br /> Address ' <br /> �> ,�4,� l C����-�S rf <br /> Cit State Zip <br /> �� C� — �,�C!! <br /> Phone � <br /> I understand my rights as stated above. <br /> �,�, ,2-��-��'i'�� � � <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMIIVISTRATIO[Y 8r.FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSIN G <br />