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� � . � <br /> , <br /> �� �� . � ����� (�I'�'�' O� ��►��T(� <br /> �,� y �,. <br /> �. <br /> ��i rJ��A���.�5'��' �L' t�``. <br /> w`{��r� t� +-�"� Post O�ce Box 66•Crystal Bay, Minnesota a5323•Municipal Offices <br /> .�¢-� <br /> �.. <br /> .r��,. ,: • <br /> � _ � � 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 wou3d 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 /> 1. 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 Iicense. <br /> 3. The information may be shared with other local , state or <br /> federal agencies to the extent necessary to grocess the permit or <br /> license. <br /> 4. If your reauested permit or Iicense requires Councii action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 �o review pri�a�� <br /> data on yourself. <br /> E. Your full name is required to process this applica�icn or <br /> permit. <br /> ��or � ���-�K- �`��-- <br /> First <br /> Middle Last <br /> � � [ � � � ��W � �� � � � <br /> Address � <br /> � �� � � I�� �� s S� � <br /> City State Zip <br /> C� � i - c� Z� � <br /> Phone <br /> I un erstand my rights as stated above. <br /> r, <br /> � <br /> Si ature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATIOI�1&FINANCE —473-7358 <br /> • PUBLIC WORKS —��3-�359 <br /> ASSESSIN G <br />