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. <br /> �� _ i <br /> -� � ' <br /> =�- ����' o� ����T� <br /> a� Post Office Box 66•Crystal Bay, Minnesota 5�323•Municipal Offices <br /> 0 <br /> : � - � g;- On the North Shore of Lake l�finnetonka <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 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 confidentiaZ information. <br /> You are notified that: <br /> 1. The information you furnish wiil be used to determine your <br /> quaiification for the per•nit or I.icense recuested. <br /> 2. You may refuse to supply data, but re=usal may require that <br /> the City deny the pernit or I.icense. <br /> 3 . The information may be s'r.ared witn o�zer iocal , s�a�e or <br /> federal agencies to the extent necessary to process tne permit or <br /> iicense. <br /> a. If your requested pe�-�nit or Iicense _ecuires Council ac��o% <br /> to approve, some infor:nation may become pu�?ic. <br /> :, . You have certain rignts unaer M.S. ?3 . C� to rev_ew private <br /> data on yourself. <br /> 6. Your full name is required to process this appZication or <br /> pe�-mit. <br /> 1 ,Z v c.-Z ��Z.�-v'-y,, C:�G� � � <br /> �'irst Mi ' 1e Las� <br /> ��li � F� ���l;�c`✓\��� L :✓ <br /> Address <br /> j,- '( „� �S�/�-( �-- <br /> C ty State Zip <br /> ���J � C�J�� �� <br /> Phone ' <br /> I unde_stand m rights as stated above. <br /> � � _� _ � <br /> _ / r--- <br /> `� <br /> Signat re . <br /> t3U1LDING& ZONI�G -473-7357 • AD,�tINiSTRATION& FIV��NCE - 473•73_3 • PUBLIC 1VQRKS -473•%3�9 <br /> ASSESSIV G <br />