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-=- � <br /> "� � , <br /> .YF%{+.Y � ::�A. <br /> �, � '� <br /> � 1S:� <br /> �� " (i�'��Y o� O�(��+i� <br /> �� .���: <br /> - - ��.: <br /> � �""""' Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> � <br /> � - � , �, On the North SJzore 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 /> 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 refusa3 may require that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with other local , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Councii ac�ior. <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> �;�-�'���,�:► f ��:�1����C IC_ jj I j�C V-� 7� _ <br /> First Middle Last - <br /> ��� Zlr � �J 1�titi` �"V�Y�.�. <br /> Address <br /> I��`�Y Z._1 i�� ��1;\; S� 3�I i <br /> City State Zip <br /> l�► Z g-)► - ��.�`� <br /> Phone <br /> 2 ��derstan'd�y rights as stated above. <br /> f <br /> '; � • , � ---__-�—� <br /> � <br /> Signature <br /> BUILDING&ZONI[YG—473-7357 • ADMINISTRATION&FINAIVCE—473-7358 N PUBLIC WORKS—473-7359 <br /> ASSESSING <br />