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�g F��,n:�'�'au� <br /> , �a�e�t � r�.� <br /> ��t�� ��� �r C ITY of ORONO <br /> �a �. <br /> .sY! �_: .)i.;� <br /> �� ~ V��` `'�'""' Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> t : <br /> � <br /> e - � � 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 Iike to inform you that your request for a permit or <br /> license f rom 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 Iicense. <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 ac��ar. <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 /> 6. Your full name is required �o process this application or <br /> permit. <br /> �/�L�?'��1;� /�_ ,����— <br /> First Middle / Last <br /> �-/ `f � ��-//lCr���7`� �<l <br /> Address <br /> � <br /> (,�-�� , Z�--�� /� I�'' � � �� <br /> City State Zip <br /> �f7� / ;��¢ <br /> Phone <br /> I unde and my rights a stated above. <br /> � � � <br /> / ��, <br /> Signature / <br /> � <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION& FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSI�G <br /> f <br />