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�! . _ <br /> -�:���,- � ���__ . <br /> :�'�������. <br /> �� �-�� ��'��' o� �R�I�� <br /> n�=>_�-,.-'�.�°"�`,..:�':�� <br /> c:=z"��i�',y ��� <br /> �V" <br /> ��'` R�`���;:� Post Office Box 6fi•Crystal Bay,Minnesota 5a323•Municipal Offices <br /> ,� :� <br /> �:�a�ai?T� � . . <br /> � �y;.„�,a�. <br /> � _ � o On the North Shore of Lake hfinnetonka <br /> DATA PRIVACI' ADVISORY <br /> In accordance with M.S. 13.04 , Subd. 2, "Rights of sub ermit or <br /> data", we would 3ike to inform you that your request for a p <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 Iicense requested. <br /> 2. You may refuse to supply data, but refusa3 may require that <br /> the City deny the permit or 3icense. <br /> 3. The information may be snared with other Iocal , 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��o% <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 proc�ss this applicatian or <br /> pe�-mit. <br /> ��� ���,,�� l�-�,��-¢�.�� . <br /> Middle Last <br /> Firs1 h �� �� <br /> 3� 35 r <br /> Addr ss <br /> �✓4� ��`� S S 39� <br /> City State Zip <br /> ��� - ���� <br /> Phone <br /> I understand my ights s stated above. <br /> � �� <br /> Signature � <br /> BUILDING&ZONING—473-7357 <br /> • ADMINISTRATION&FINANCE —�i%3-7358 � PUBLIC WORKS —473-7359 <br /> ASSESSING <br />