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J. <br /> I4 � <br /> �� CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minneaota 55323•Municipal Officea <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 reguest 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 /> 1. 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 iocal , state or <br /> federal 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 to review pri�at� <br /> data on yourself. <br /> E. Your full name is required to process this appl.ication or <br /> permit. <br /> ���1� �- S��/�� ��� �S�� <br /> First Middle Last <br /> l��v ��U��ti� ��r <br /> Add ess <br />� .���1,��� U'����� /��t0 - �� 3 3 <br /> City State Zip <br /> �`��- 7 7��-.- <br />� Phone <br />, I understand my rights as stated above. <br />� ' V <br />� <br />; Signature � <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE —473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />