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� h+�`� <br /> � <br /> �� <br /> � . <br /> �A. �xr�c� . <br /> �'�«s��a K.f _�:.. <br /> �k��`���,��.�� �i��� O� ����� <br /> ..�,.,... <br /> � � Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> � ' <br /> a - � . �. 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 like 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 /> l. The information you furnish will 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 �oca I , state or <br /> federa]. agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 �o review pri�at� <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> C�U k'�l l�f�-P!+���1 <br /> First Middle Last - <br /> ���-1-9 �'��►�(L�s ��� rzl� <br /> Address <br /> ���1'Y 2-�'f� Uti �I 5 S��'1 1 <br /> City State Zip <br /> 1-tll -� t �L <br /> Phone <br /> I understand my rights as stated above. <br /> � r <br /> —� <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMIN[STRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />