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< . t . <br /> . .. . � <br /> -,�;. <br /> ', y,; � r <br /> "A � :� ! <br /> _� ��t '� ���x.� � <br /> �� ` `4� ' ' CITY of ORONO <br /> r >'� �r _ ; <br /> w <br /> FSt y�,h �.�Y 7 <br /> � y' �, � <br /> '� A: �. � Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> ��'i . S�7i <br /> � ��r,t�v �'.`Y �.; <br /> }�q.,�� 'ik <br /> � - � �,�: :� On the North Shore of Lake Minnetonka <br /> .u.. 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 /> 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 /> l. The information you furnish wil.I 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 grocess the permit or <br /> license. <br /> 4. If your requested permit or license requires Councii action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> E. Y�ur full name is requirect to process this applica�icn or <br /> permit. <br /> /�� a �,� �// <br /> ( � � ��l� ��..��` �;�"�-,f( �/�%��1'-f'�r' �C <br /> First Middle Last <br /> � _ <br /> C-'ef ��r � � �� L � � �, <br /> Address <br /> _. —� <br /> , � � <br /> ����{ �,���� �r ll� ,� �� �- ✓ �' <br /> City State Zip <br /> �� �� �� _ �� � <br /> Phone <br /> I understand my rights as stated above. <br /> ; ,�7 �r-..._--. /// <br /> . ��L�/ / � Q �"�l.��"�E'(��-,."'�'. <br /> .�� i ,;2..----�—' � <br /> Signat <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION& FINAtiCE —�373-7358 • PUBLIC WORKS—473-7354 <br /> ASSESS[N G <br />