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a � <br /> �-� ��� <br /> ^r�...�� ����,; <br /> _�.? y �-;K , <br /> ���� y��,�° � ��� O� ����� <br /> , � <br /> r t � �'"�-�� - <br /> �..w:`�.3�e-"` � ' <br /> .�-- ,; �<:. <br /> ��:„. „� � :,. <br /> ��� Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> .,�: <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 like to inform you that your request for a permit or <br /> 3.icense 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 /> qual.ification 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 shared with other local , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> 3.icense. <br /> 4. If your requested permit or Iicense requires Councii ac��or. <br /> to approve, some information may become pub3ic. <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 /> TI A�c %c� � �.ti Gc S���t <br /> First Middle Last <br /> � �� �: �iitir � (��2� ` G_- <br /> Address <br /> C c /v, .� S"�s._ G <br /> City - State Zip <br /> ���- ; 3 �L - <br /> �r. y <br /> Phone <br /> I understand my rights as stated above. <br /> ------� <br /> � �� _ - -- <br /> Si ature "--- � <br /> BUILDING&ZONlNG—473-7357 • ADMINISTRATIOIY& FIIYANCE--i73-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />