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' � � <br /> ����°�' _ <br /> ,��; <br /> ,Y, <br /> �F��� �.��W. <br /> : Q��� f,���:� �(i I'1'I' Of (�R�1�T0 <br /> ��.},.��i <br /> :�:w�.�.:��:�;:;�. <br /> �N"�" �` � ' Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <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 /> license from the City of Orono or any of its departments may require <br /> you to furnish certain private or confidential info�mation. <br /> You are notified that: <br /> 1. The infor;r.�tion you furnish wil.l be used ta determine your <br /> qualification for the permit or Iicense requested. <br /> 2. You may refuse to supply data, but refusal ma� require that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other Iocal , state or <br /> federal agencies to the extent necessary to prc�cess the permit or <br /> Iicense. <br /> 4. If your re�uestac,� ge?-*^�.t �;r Iic�_�;�e requi.res C:�unci I action <br /> to approve, some inf�rmation may become public . <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�e <br /> data on yourself. <br /> 6. Your full name is required to process t?zis application or <br /> permit. <br /> �6 t�F��D � J�--m �S �E� rv� E�l2 <br /> First Middle Last � <br /> �i �S' t=o R �S T ,4�.w�s ��-N e _ <br /> Address <br /> Vv"�� o � n� � �'l /v � s�� � � <br /> City State Zip <br /> �f � � — �� 13 <br /> Phone <br /> I understand my rights as stated above. <br /> K.�-O`"v`-o�`�l ` - <br /> Signature <br /> BUILDING&ZOIYING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />