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� -� <br /> ..:"�� <br /> ,,� �,R�� <br /> - �� CI'�'�' O� �RO1�0 <br /> .� � <br /> " a3_ Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> � _ � � On the North Shore of Lake Minn.etonka <br /> DATA PRNACY 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 /> l. The information you furnish will be used to determine your <br /> qualification for the permit or license 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 local , s�ate or <br /> federal agencies to the extent necessary to process the permit ar <br /> license. <br /> 4. If your requested permit or Iicense requires Counci3. ac��o% <br /> to approve, some information may become public. <br /> �. 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 /> permit. <br /> .ST���� � �!'N��� <br /> First <br /> Middle Last <br /> 17.��—�ia'�a�s'� �,�6 7/� <br /> Address <br /> � � ����� <br /> j''Ii�t/v✓t'.7�G ,�� Z1P <br /> City State <br /> �j� °z�'� <br /> Phone <br /> I understand my ri ts as stated above. <br /> � <br /> Signature � � <br /> BUILDING&ZONING—473-7357 <br /> • ADMINISTRATION&FINANCE--373-7358 � PUBLIC WORKS —473-7359 <br /> ASSESSING <br />