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� <br /> � <br /> CI'T'� O� ORO�TO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> o - � � On th,e 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 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 refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other 3.ocal , state or <br /> federa3. 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 prica�� <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> ���ti��� ��v 4, � �dL`.�..l,.�r'-� <br /> First Mid le Last <br /> - c-•. <br /> `7 ��� �� � � J� ►�- ��- .�-�--- � � - <br /> Address <br /> �x���_��,c� � G�c1 ��� �" � <br /> City State Zip <br /> `� u ct �-- S i �- �— . <br /> Phone <br /> I understand my rights as stated above. <br /> � ��ti-a� �� �� � <br /> Signature � � - : <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING � <br />