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. . ' <br /> , ,� <br /> � <br /> -� } � <br /> �..,.�� a..<_�,} ._ <br /> : a�1 t . ". <br /> a <br /> t�: ' : , � �ITY of ORO�TO <br /> �, <br /> :� g <br /> „ �;, r ,� <br /> Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> � �y a��i <br /> � - o o 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 3ike 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 confidentia3 information. <br /> You are notified that: <br /> 1. The information you furnish wi3.1 be used to determine your <br /> qua].ification 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 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 /> license. <br /> 4. If your requested permit or Iicense requires Councii act�or. <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 yoursel.f. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> f�"�/-7i�/� /�-c - --��� j� �-, _ ' �_7 <br /> First Middle Last <br /> _� � , � - �",� � , `a l j S�y� j�.�,�,_� <br /> Address <br /> l�'A� "����1�, �` '%✓ S`��J i <br /> City State Zip <br /> �-r/ �%����� <br /> Phone <br /> I understand my rights as stated above. <br /> --J <br /> �, <br /> %= <br /> � , <br /> i'; , �� < J z ��-r,�" ��% <br /> Signature <br /> BUILDING&ZOIYING-473-7357 • ADMINISTRATION&FINANCE-473-7358 • PUBLIC WORKS -473-7359 <br /> ASSESSING <br />