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� � <br /> .� � " � ����� <br /> ����' o <br /> N� Post Office Box 66•Crystal Bay, Minaesota 5a323•Municipal Qffices <br /> ! <br /> • ' • ' • <br /> On the North Shore of Lake Minnetonka <br /> DATA PRSVACY AD�SORY <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 /> 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 snared with ot=o�sscthe permit or <br /> federal agencies to the extent necessary to p <br /> license. <br /> a_. If your requested permit or Iicense requires Councii ac��or_ <br /> to approve, some inzormation may become publ.ic. <br /> 5. You have certain rights under M.S. 13.0a to review priva�e <br /> data on yourself. <br /> 6, Your ful.l name is reauired to proc�ss this application or <br /> permit. <br /> 9 � . <br /> 2 � � <br /> -/ �� �r <br /> � � Last <br /> Firs} M1 Ie <br /> 9.;� �; �=�� �� �5� ��2��s �-�� — <br /> Address _ � / ; <br /> � a �.�.r,� /��n( �� � � y <br /> City <br /> State Z1p <br /> ���,�-' � /��9 3 <br /> Phone <br /> I understand my rights as stated above. <br /> r �J . <br /> Sign ure � <br /> BUILDING&ZO`11NG—473-7357 • ADMiNISTRAT'IOiV&FtNANCE—473-7358 <br /> • PUBLIC`NORKS —473-7359 <br /> ASSESSING <br />