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� <br /> .. , , , <br /> �¢7p,tyY4y4' ,gS ��Y ly�`�� :��e^'�,;..� <br /> R <br /> -y ., r { a� �.ia. <br /> . a + �-,`t '� aha.� sr <br /> � �� "`�:� C I�Y of O�ON� <br /> g F:r f�,+�.... <br /> , *r.� ��;�t'4 n.a- <br /> �S 3.� m <br /> n ,. . <br /> �:5r:�+'ais"v".:Y�r��..s,'�:. <br /> �Y� ��� �"" Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> i�.; <br /> �� �t�i?G$;: <br /> ..,,�7;��,..,. <br /> � � ;�' r,� On the North Slzore 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 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 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 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 privat� <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> �-� � .i <br /> �� ��; .�c�a � � T � ���� � , � 1 � � <br /> First Middle Last <br /> v. �% ; r�-�x /� 2� <br /> Address <br /> �✓' � S 7"� / �� �� V i2� /7, ,5 5..3 2 .3 <br /> Cit State Zip <br /> �--� �:-� _ l��/ � � <br /> Phone <br /> I understand my rights as stated above. <br /> .� ,"' - <br /> � ?� r� � � �� <br /> Signature <br /> BUILDING&ZOfY1NG—473-7357 • ADMINISTRAT[ON&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br /> � <br />