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� ��r�- <br /> � �����Y'� � <br /> ��� " ��'��.' �� 0���� <br /> r z,�ti,-� m' f ,�. ' <br /> ; �' F�.; �� .. <br /> �� t'i7 X ��' <br /> �'*s^� ..t;. Sr . _ <br /> r„�ar� <br /> T.�t ,�,_, Post Office Box 66•Crystal Bay,Minnesota a5323•Mu�ap� ' � <br /> • <br /> �" � _ v �- On the North Shore of Lake �lfinnetonka <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 from the City of Orono or any of its departments may require <br /> you to furnish certain private or confidential infor.nation. <br /> you are notified that: <br /> 1. The in�ormation you furnish will be used to determine your <br /> qualification for the permit or license reques�ed. <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 IocaZ, state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense recruires Councii action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�at� <br /> data on yourself. <br /> 6, Your full name is required to process this applicatic� or <br /> perm't. <br /> � <br /> �Lti�� �-- <br /> First <br /> M' ddle Las� <br /> 1 ��� � �� �.� `� <br /> Address -� l <br /> a �. ���--� _� ��_5� � � <br /> City State Zip <br /> t� �� -�� /_� <br /> Phone <br /> I und rstand my rights as st ed ^above. <br /> � �� <br /> � � ,C,r�-�. . <br /> Signature � <br /> BUILDING&ZOtY1NG—473-7357 • ADMINISTRATION&FIN?,NCE—473 T358 <br /> • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />