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. <br /> i � <br /> � <br /> �, <br /> CITY of ORONO <br /> `M Post O,ffice x 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> � °`, , <br /> � �`;' <br /> „ � _ � e On the North Shore o Lake Minnetonka <br /> DATA PRNACY AL�VI ORY <br /> In accordance with M.S. 13.04, Sub . 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 confide tial information. <br /> You are notified that: <br /> 1. The informativn you furnish �wi 1 be used to determine your <br /> qualification for the permit or Iice� se requested. <br /> 2. You may refuse to supply dat'a, I ut refusal may require that <br /> the City deny the permit or licenise. <br /> 3. The information may be shar�ed with other iocal , state or <br /> federal agencies to the extent nece sary to grocess the permit or <br /> license. <br /> 4. If your requested permit or Ii ense requires Councii action <br /> to approve, some information may be ome public. <br /> 5. You have certain rights under M.S. 13.04 to revzew pri�ate <br /> data on yourself. <br /> 6. Your full namP is required to rocess this applicaticn or <br /> germit. <br /> ,Q�l,��/� K�C t�tZ1� � Su� <br /> First Middle Last <br /> lvS KS ► F , <br /> Address , <br /> �,(C� �/ � S3"3 �J cl <br /> City State � Zip <br /> �-�� - ��� -� � <br /> Phone <br /> I understand my rights as stated a ove. <br /> ,��� �� � <br /> Signature <br /> � <br /> BUILDING&ZONING—473-7357 � ADMINISTRATION&FINA CE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />