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� c <br /> �_ , � . ����' o� O���O <br /> «� Post Office Box 66•Crystal Bay,Minnesota 5�323•Municipal Offices <br /> ! <br /> � _ � � a On the North Shore of Lake Minnetonka _ <br /> DATA PRNACY AD�SORY <br /> In accordance with M.S. 13'ou�thatdyour request for a permit or <br /> data", we would like to inform y require <br /> license from the City of Orono or any of its departments may <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your <br /> aualification for the permit or I.icense requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> tne City deny the permit or license. <br /> 3. The information may be snared with ot=OCe scthe pe=mit or <br /> f ederaZ agencies to the extent necessary to p <br /> ?icense. <br /> a, If your requested permit or Iicense requires Councii ac��o% <br /> to aporove, some information may become public. <br /> 5 . You have certain rights under M.S. 13.04 to review priva�e <br /> data on yourself. <br /> 6. Your full name is required to proc�ss this application or <br /> per•nit. <br /> ,� ` � � C�.r� 5 -�� a�s � <br /> ��a-`l l �5 � c. �v- <br /> Middle Last <br /> First � 1 <br /> �4(SI �4 e,� v�e.55 Qk `� <br /> Address <br /> D�o � o �� 5534 / <br /> City State ZiP <br /> ,�� � � �-� a- <br /> Phone <br /> I understand my rights as stated above. <br /> Signature � <br /> BUILDiNG&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 <br /> • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />