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. �. <br /> �'����.. <br /> -::-�-�:,��; <br /> �°�;� ���:.-.:,� <br /> ��� <br /> ;;,.,�,�.:. �� . = <br /> �� � <br /> °� � � ��'�I' o� O��IOTO <br /> s »,�C�. <br /> '�. � � 4 <br /> �; ya <br /> -r:,S; ��+;e.:.�.,. <br /> � -..r_�:r'.. <br /> ; r��'�: Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> 9 ;k;:"� <br /> • - • ��' On the Nortlz 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 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 license 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 snared with other Iocal , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Zicense 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 proc�ss this application or <br /> permit. <br /> �� ���� ����t <br /> First Middle Last <br /> 'i��J � � �:� � _ � 9 <br /> Address <br /> � ��, �� ���� <br /> City State Zip <br /> �'�� -� ��f�� <br /> Phone <br /> I understand m r' g t as stated above. <br /> � , ;��l• -� _. <br /> Signature <br /> BUILDING&ZON[NG—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />