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:; >s.._, <br /> E <br /> � ��"�'���.�f` <br /> `, s a�:� <br /> � ,�, : <br /> � :s:�,,�� �;�� ,; ���� O� ����� <br /> � ����� :� y,:� <br /> ,�,w� _, ,� Post Office Box 66•Crystal Bay, Minnesota 5a323•Municipal Officea <br /> a:'.:. • ..., <br /> ` � ; .r� <br /> � � �`��` ' On the North Shore of Lake Minnetonka <br /> s - • . �.�, <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2 , "Rights of subjects of <br /> data", we would 3.ike 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 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 /> license. <br /> 4. If your requested permit or Iicense requires Councii action <br /> to approve, some information may become public. <br /> 5. You have certain rights ander M.S. 13.04 �o review pri�at� <br /> data on yourse3f. <br /> 6. Your full name is required to process this apr-Iicatica or <br /> permit. <br /> ��/�/�C�S /'�C����� �� � �'��,� <br /> First Middle Last <br /> ,�S`��� �;��s �; �,��S ��'� <br /> Address <br /> �5 �.. <br /> �l�t9di� % ��/ �°V` �� � � <br /> City State Zip <br /> c,J�.�� <�j � �- <br /> Phone <br /> I understand my rights as stated above. <br /> _ ,i" ' � <br /> � � � � �� <br /> c ,�� � � �� L� � <br /> S gfiature <br /> BUILDItiG&ZONING—473-7357 � AD'1tINISTRATION& FItiANCE —473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSiN G <br />