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� �. <br /> ��,;y� <br /> ,� � �. �i.., <br /> �4 � <br /> � � <br /> � � cITYo� oRo�o <br /> . ,�,� ��� <br /> � ��-� ��, <br /> " f � �<" 3 <br /> A� '" � Post Office Box 66•Crystal Bay,Minneaota 55323•Municipal Offices <br /> 9° ��' �;' ; <br /> I�" � �� �`�" '"� On the North Shore of Lake Minnetonka <br /> r <br /> a�;. � �� e.; <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2 , "Rights of sub;ects 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 confidentia.Z information. <br /> You are notified that: <br /> 1. The informativn you furnish wi3.1 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 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 Council 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. Yaur full name is required to process this applicatioa or <br /> permit. <br /> � �: <br /> !-- /, <br /> , � �,�, <br /> c ;_��. �r � ��T,�'—� - �,�� <br /> First , - iddle � Last <br /> �,. �s ' �` r <br /> `� � '� <br /> �� -, El � i'��� '�v� i E'�-�-` <br /> Address �. -` <br /> \_� � ��',�/j 7 /_�- �� `��� � <br /> City State Zlp <br /> .�- <br /> �� � ('� �"�;�, �`.�--__ <br /> � _ �. _ <br /> Phone <br /> I understand my rights as stated above. <br /> Signature <br /> BUILDING&ZONING-473-7357 • ADMINISTRATION&c FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING ` <br />