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#�:.a: � � '.�i <br /> .�y,,,� �. .._ <br /> � a. . ���� �� ����� <br /> Post Office Box 66•Crystal Bay,Minnesota 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 wi3.1 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 , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Councii. ac��or. <br /> to approve, some information may become publ.ic. <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 appl.ication or <br /> permit. <br /> �t�oQ�-�C �..'1i�2-"t" �AMt E � ��- <br /> First Middle Last - <br /> 39 � t ��sT 3 ► s-2 �vT¢.��� T <br /> Address <br /> S'T. L�u t S 1�6.2-1` �''t r� • 5 5 4 I t� <br /> City State Zip <br /> <�IZ-� �1.-�.' � o��- <br /> Phone <br /> I understand rights as stated above. <br /> ' . <br /> Signature � <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE —473-7358 • PUBL[C WORKS —473-7359 <br /> ASSESSING <br />