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. � <br /> �� <br /> �� � <br /> � � �. <br /> � �� :� <br /> ' � . R4N� <br /> � : : CITY of O <br /> : � �,� <br /> ��.� <br /> ��3��,. ,;? Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> � -�r <br /> ��. �=n ,:�� <br /> �'"_ � a � : On th,e NortJz 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 like 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 /> 1. The information you furnish wiZl 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 Iicense. <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�� <br /> data on yourself. <br /> 6. Yaur fulZ name is required to process this applicaticn or <br /> perfiit. <br /> ✓ <br /> �2�� . �`� � r <br /> First Middle Last <br /> I I�� C�� IZD , I� <br /> Address <br /> i L�II/n � j� �S �(���- <br /> City State Zip <br /> �� � - �� I � <br /> Phone <br /> I und stand my righ stated above. <br /> � <br /> Signa ure <br /> BUILDI:VG&ZONING—473-7357 • ADMINISTRATION&F[NANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESS[NG <br />