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� � <br /> � � . <br /> �s� �' ��. -,�d r� <br /> ��� # � ���� O� ���l�T� <br /> r"�sr.�fr�,G�i� �,�. <br /> k+.�w�.a�,�rvc+� ��.... ..., <br /> �.teaf.:'�M.raJ�+e w'-:.�f.k..:: <br /> � j�'��.� .� Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> �:: <br /> r �: a .�, - <br /> ��� ,� :,��. On the North Shore of Lake Minnetonka <br /> DATA PRNACY 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. information. <br /> You are notified that: <br /> 1. The information you furnish wi3.I be used to determine your <br /> qualification for the permit or license requested. <br /> 2. You may refuse to supply data, but refusal may reguire that <br /> the City deny the permit or l.icense. <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�a�� <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> R �f� a-�� �e.�c��{^ 1✓ ��rC ��_{' <br /> First Middle Last � <br /> �) � i�i �1 i=� �l� ��' �LJ �• �� — <br /> Address <br /> 'of�f /y�� , ,.�'��3.� % <br /> �ty State Zip <br /> G � � � � �rS 7 +a2`// Jr <br /> Phone <br /> I understand my rights as stated above. <br /> �j '^ _ <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMIN[STRATIO[�i&FINANCE—473-7358 • PUBL[C WORKS—473-7359 <br /> ASSESSING <br /> �� � <br />