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�� `��� -- <br /> �-��`i�� <br /> � � � ���N'� <br /> � 5{ ri � CI'�'I" � <br /> - �,1... <br /> Tz.�4: <br /> ';���-,.���"�-�,. Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> , �'.�: <br /> :�=�::� <br /> � _ � � On the 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 /> Iicense 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 require that <br /> the City deny the permit or license. <br /> 3. The information may be snared with other Iocal , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> Zicense. <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 /> permit. <br /> S�l��r.��� ��'� <br /> First Middle Last <br /> �k� � - <br /> Aadress <br /> � �� � ����� <br /> �City State Zip <br /> �'3��- o3s� <br /> Phone <br /> I understand my rights as stated above. <br /> �' <br /> ` _. <br /> Signature � <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 � PUBLIC WORKS —473-7359 <br /> ASSESSING <br />