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J / <br /> � # �3 <br /> �,1. ':}s�� <br /> � ' <br /> y`� �� � �� � C�'�� O� �'liONO <br /> �� �� �,�a.; <br /> � �,�� �.�7:� <br /> ' s ��._�.: <br /> :' � `}'""� �T`� Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> i;rr�..;:�� <br /> �y=`:M � - <br /> x�d On the North Shore of Lake Minnetonka <br /> � :o �„�: <br /> DATA PRIVACY 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 /> 3icense 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 wil.l 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 local , state or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Councii actior. <br /> to approve, some information may become public. <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 process this application or <br /> permit. <br /> �P�-"� � �, �") <br /> ' rst "Middle Last <br /> Fi <br /> �j3 Z� G 1��-�i1 �� �-t-� f <br /> Address <br /> ,..� �r 1�, �. �3`�� <br /> City State Zip <br /> � l I � 9' <br /> Phone <br /> I understand my rights a��tated above. <br /> Sig ature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&F[NANCE —473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />