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� ' r <br /> Y,� zk�, f <br /> �t � w y t <br /> p. � �Aa�,�,,, <br /> � J �� � CITY of OR4N0 <br /> �� <br /> '`' ������ ;�� < <br /> / � � k� <br /> F��t-",�` <br /> ;._ ', � ,,",��' :, Post Office Box 66•Crystal Bay,Minnesota 5a323•Municipal Offices <br /> �.. <br /> • `'� <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 Iike 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 thai <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 /> license. <br /> 4. If your requested 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 to review pri�ate <br /> data on yourself. <br /> 6. Yaur fulZ name is required to process this apglicaticn or <br /> permit. <br /> ,f�►�-� �,��,�� ����•yP��.�/ <br /> First Middle La t <br /> �� �'�r,���� /�� <br /> Address <br /> /��d�.� ��'� ���� <br /> �lty State Zip <br /> y�� ���. <br /> Phone <br /> I understand my rights as stated above. <br /> Signature <br /> BUILDING&ZONING-473-7357 • ADMINISTRAT(ON&FINANCE-473-7358 • PUBLIC WORKS -473-7359 <br /> ASSESSING <br />