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� <br /> . � <br /> �'''��..- <br /> � F�', <br /> �„i` t �� s .� ,::� <br /> ��`a' �..��.'�a � � (���'Y O� ����� <br /> L 3'�'A�'�i+� Pj�S' ! '.5` <br /> 'L'_�.'r� � .��..:A <br /> 4 t.j'�fiS .J_�f > .e'}:..1 <br /> �"1: 7x.�,�..:a <br /> ;��' ,��.,„ s '�� Post Office Box 66•Crystal Bay, Minnesota 5a323•Municipal Offices <br /> �:r;__•�� :,_,N�:-,- ;`{ <br /> • <br /> � _ � o On tize 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 request for a permit or <br /> license f rom 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 /> qualification for the permit or license 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 oth��r esscthe permit or <br /> federal agencies to the extent necessary to p <br /> Iicense. <br /> 4. If your requested permit or Zicense 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 process this application or <br /> permit. <br /> �/��-, � OSTIi,� <br /> First <br /> Mi le Last <br /> %S7 � �o� � �, � �( qo <br /> Address <br /> 4 �,�� -, �. .� S�s� 31' S' <br /> City State Zip <br /> �=� � � - 3� // <br /> Phone <br /> I understand my rights as stated ove. <br /> �� <br /> Signature <br /> BUILDING&ZONING-473-7357 <br /> • ADMINISTRATION&F[NANCE-473-7358 • PUBLIC WORKS -473-7359 <br /> ASSESSING <br />