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. <br /> ������;'� <br /> � �dt KaY`'iy�. <br /> � <br /> �rt�`t � � � CITY of ORONO <br /> Post Office Box 66•Crystal Bay, Minneaota 55323•Municipal Offices <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 /> license 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 wi3.I 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 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 Councii action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�e <br /> data on yourself. <br /> E. Yaur full name is required to process this applicatian or <br /> permit. <br /> ��r r �� I I b�►���-- �5�.�. <br /> First Middle Last <br /> � �� r�1�_ �(�?, ( �, ��..�, � (�� <br /> Address <br /> � � ( �..I d'��� ►'��3� � <br /> City State Zip <br /> �� (� -�- ��1 � � _ <br /> Phone <br /> I understand my rights s stated above. <br /> l <br /> GZ,� r <br /> Signature <br /> BUILDING&ZONING—473-7357 � ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESS[NG <br />