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Y <br /> •^r�,,,�-a. 'd�,�>. <br /> +.... ���; <br /> � ��` <br /> ��� �� �i��� O� ����� <br /> �; . �} <br /> .:�.� :�.� <br /> _� � ,:, <br /> .������ �� Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> _ ,,..� ����� <br /> .: .,.t.�. =;s,, <br /> � - e �; On the North Sh.ore of Lake Minnetonka <br /> DATA PRNACY 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 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 reguire that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with other local , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii ac��or. <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 procass this application or <br /> pe!�mit. <br /> �1�v'�, �s �� �c�/C�Lt: ►��t�l <br /> First Middle Last <br /> "�iL��� "r✓.�-f.-- � /-�c.i�. IV . <br /> � . .-� <br /> Address <br /> Le.-a��a�c� ��'.-� ``�s�t'��7� <br /> City State Zip <br /> 1��' ��a ,vA <br /> Phone <br /> I understand my rights as stated above. <br /> ��-� � �' -- <br /> Signature <br /> BUILDING&ZON(NG-473-7357 • ADMIN[STRATION&FINANCE--i73-7358 • PUBLIC WORKS -473-7359 <br /> ASSESSIN G <br />