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�" ,�..o <br /> ��� � (��"�'�' o� ����T� <br /> Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> i <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 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 /> 1. The information you furnish wil.I be used to determine your <br /> qualification for the permit or Iicense 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 Iocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Council activn <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 �o review pri�a�� <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> � <br /> � i ��'j�' " j � _ � �j� �� <br /> First Middle Last - <br /> � <br /> �� - .� � r '� <br /> Address <br /> ; . - ��� / =�,, <br /> City State Zip <br /> �_.�., ., - � . <br /> - ,v--� � '��-�-- <br /> Phone <br /> I understand my rights as stated above. <br /> , ✓ <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADM[NISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />