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� <br /> :� � <br /> � CITY of OKONO <br /> � <br /> z Post Office Box 66•Crystal Bay, Minnesota 55323•MuniciPal 0��� <br /> • <br /> � _ � � 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 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 /> l. The information you furnish will 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 Ioca1 , 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��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 /> V`� � �� Yl�� L� V� Vv� S 0 <br /> First Middle Last <br /> -�j 3 � � �v��. � ��. � l� �G C� � <br /> Address <br /> � 1'�(�Yl D �'�'� b�1 ,S��� � � <br /> City State Z1p <br /> y`l1 - � � 3 �1 <br /> Phone <br /> I understand my rights as stated above. <br /> � � ��� <br /> C� J1,�--C�G � � <br /> Signature <br /> BUILD[NG& ZONING—473-7357 • ADMINISTRATION&FINANCE —473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />