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i <br /> ����4 ,M1 . <br /> ��� <br /> � � } <br /> ` `� CITY o� OR�NO <br /> �-��=t� _ ; � <br /> � c , y <br /> W:. <br /> r-, ti- <br /> �i1'$�"��' d' t <br /> r � Y�- Post Office Box 66•Crystal Bay,Minnesota 55323•MuniciPal Offi�es <br /> `4.��^'v <br /> � <br /> � _ A �� On the North Shore of Lake Minnetonka <br /> D.ATA 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 /> qualif�cation 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 ot rocessCthe permit or <br /> federal. agencies to the extent necessary to p <br /> Iicense. <br /> 4. If your requested permit or be ome e b�uc res Council. ac��or. <br /> to approve, some information may F <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 procnss this application or <br /> penr►it. <br /> F;=St :�pRiZ���`��OFING Last <br /> 1333 Larc industrial Bivd. <br /> Address Ut'nSVi 2, <br /> City State Zip <br /> ��o - ?�� � <br /> Phone <br /> I understand my rights as stated above. <br /> /�/� ��0 <br /> /��,IL�,i� �%1(�` ��,� <br /> Signature �- � <br /> BUILDING&ZON[NG—473-7357 <br /> • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />