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��_ <br /> �'`x� v��: <br /> �� � <br /> ..,,�..�: � � �: (��'�I' o� O��NO <br /> � <br /> :-.y � ' Post Office Box 66•Crystal Bay, Minnesota 5�323•Municipal Offices <br /> '.=-'�� .� <br /> �`�, On the North Share of Lake Minnetonka <br /> � a'- � o <br /> DATA PRIVACY 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 /> l. The information you furnish wil.l be used to determine your <br /> qualification for the permit or Iicense requested. <br /> 2. You may refuse to suppl.y data, but refusal may require that <br /> the City deny the permit or Iicense. <br /> 3. The information may be snared 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 ac�ior. <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 to process this application or <br /> permit. <br /> ,�� l � ;� � ° �<���� <br /> � � Last <br /> First ` Midd e <br /> �,� - , i� ' / <br /> _> , „ <br /> ,. _ �.. ��.� ,,� � _ �, <br /> Address <br /> /��';.,�'.��' ,L �, , �i`%� -'--'� f� <br /> Cit� State Z1p <br /> -�, <br /> ��. .. - / <br /> Phone <br /> I understand my rights as stated above. <br /> � �%. � � J � <br /> ' r�'�� - <br /> ignature `� � <br /> E3UII.DING& ZONING —473•73�7 • ADb1INISTRATIOv&FI�1�NCE— 473-7358 • PUBLiC 1yORi�S —473-7359 <br /> ASSESSI�IG <br />