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� <br /> ,�,� , ��`;�'t��t� <br /> 1 k.� <br /> A e :f ' .a �� CI�'�' O� �R01'�T� <br /> i'�'��' <°�o-1 §� <br /> v� �,, �� <br /> ��,;'�����$�� z.� Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> �� x:� <br /> �.;� � ��b� : <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 /> 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 Iicense. <br /> 3. The information may be shared with other local , state or <br /> federal agencies to the extent necessary to grocess the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Council. actio*� <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 �o review pri�at� <br /> data on yourself. <br /> E. Yaur full. namP is re�uired to process this apt Iica�ian o� <br /> permit. <br /> E�S � b�' h�s�(� ��.vt CC4.VI.SbVt <br /> ' rst Mid Ie Last <br /> ��0 C��c �.v� � <br /> Address <br /> (�� ��� Q�,N SS3 S�-Q 3 8� 30�f <br /> Cit State Zip <br /> �ZS- �3�� ; �7��f 4'3�- <br /> Phone <br /> I un rst my rights as stated above. <br /> Si nature <br /> BUILDING&ZONING-�73-7357 • ADMINISTRATION&FINANCE-473-7358 • PUBLIC WORKS -473-7359 <br /> ASSESSING <br />