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.� <br /> � � <br /> '"�=�"��-- <br /> .�� � _� <br /> '�-u��'" �3' - <br /> ���:... ��" ����� <br /> � ��'��' o� <br /> �. � <br /> �:,,��--� X <br /> �.,,_�.��,w �-: <br /> : ��, .-=. <br /> -"c.-3. . �' 'i <br /> *� ' �' �� Post Office Box 6fi•Crystal Bay, Minnesota 55323•Municipal Offices <br /> v.Y.]::s <br /> :�-`yet.:. <br /> � � <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 Iike to inform you that your request for a permit or <br /> Iicense 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 uuested, determine your <br /> qualification for the permit or Iicense req <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 snared with oth�ocesscthe permit or <br /> federal agencies to the extent necessary to p <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Councii ac��or. <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�e <br /> data on yourself. <br /> 6, Your full. name is required to proc�ss this application or <br /> permit. <br /> ---� <br /> * / � �� �` �� I' � �f �� ; /( t�� ��� C- c'� � "� t <br /> ��� 1 " �' Last <br /> First Middle <br /> > <br /> � � / <br /> �-�� S-- � � � � �, ( �:� � f�"" ��_I <br /> Address <br /> � __�� ����1� �/ S � �,�;� � <br /> � i� <br /> City State Zip <br /> l� �� _ ,'; _�/ � <br /> Phone <br /> I understand my rights as stated above. <br /> _ � -; %i j � i�� C������ <br /> � �i� ;__�- /`i �;�' 2 %r � � <br /> Signature��'� , , � � � <br /> i <br /> J � <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 <br /> • PUBL[C WORKS—473-7359 <br /> ASSESSIN G <br />