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� <br /> � <br /> . � f t;; <br /> , ;�;�_, <br /> � <br /> `��'�� � CITY o� ORONO <br /> e �;T��.." <br /> ,� �`'�'t� <br /> ��:��;�;..,.rf. <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> � _ v � 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 like to inform you that your request for a permit or <br /> Iicense 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 license 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 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 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 full name is required to process this application or <br /> permit. <br /> K�'-��r� E '�yi�� <br /> First Middle Last <br /> �S1�"— l �� �v- �- <br /> Address <br /> -Zy }-�,.�, �`� <br /> City State Zip <br /> �-`77- Il �o <br /> Phone <br /> I understand my rights as stated above. <br /> - �_ — -ta.Yt-c� <br /> ignature L.d.�E� C�-+S't'c1xToH . <br /> I <br /> BUILDING&ZONING-473-7357 • ADMINISTRATION&FINANCE -473-7358 • PUBL[C WORKS-473-7359 <br /> ASSESSING <br /> �i , <br />