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� '. <br /> �; � ��'��' o� ��►�1�T0 <br /> �� Post Office Box 66•Crystal Bay, Minaesota 5a323•Municipal Offices <br /> 0 <br /> • - • s <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 /> we would like to inform you that your request for a permit or <br /> data", of its departments may require <br /> license from the City oi Orono or any <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> l. The information you furnish wil.l be used to determine your <br /> qualification for the permit or license requested. <br /> 2, You may refuse to supply data, but resusal may require that <br /> the City deny the permit or license. <br /> 3. The informat�o the ext entnnecessaryhto processcthe permit or <br /> federaZ agencies <br /> license. <br /> a. If your requested permit or Iicense requ�res Councii ac��or_ <br /> to aporove, 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 /> pe�it. <br /> First <br /> Middle Last <br /> Address <br /> City <br /> State Zip <br /> Phone <br /> I understand my rights as stated above. <br /> Signature � <br /> BUILDING&ZONING—473-7357 • ADMINISTRAT'ION&FINANCE—473-7358 <br /> • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />