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. r . <br /> _ . �� %�� <br /> 'y "��� C ITY of ORONO <br /> � .�{.. <br /> .r. <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> � _ � � On the North Shore 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 3ike 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 /> l. 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 snared with other Iocal , 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 actior. <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�e <br /> data on yourself. <br /> 6. Your fu3.I na:ne is required to process this application or <br /> permit. <br /> �� / <br /> �cc.��l� � f 1'E-1� C..�f� ��0 !� <br /> First Middle Last <br /> � � ��l ��`i-�; C..'�o-��'L�� � L !�1� - <br /> Address <br /> �, � .=o �� � ,�'� n/ .��s y z "3 <br /> City State Zlp <br /> ��o/ Z���n �� 3�, v� � <br /> Phone <br /> I understand my rights as stated above. <br /> ` <br /> � � �L� �' <br /> ignature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FI�ANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />