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� ` ' /� <br /> �...�. - <br /> � <br /> � :�,: <br /> �` CI'��' O� �ROloT� <br /> � . <br /> r � <br /> � �j 4�l' �n.. . <br /> t�{?; �,�.. <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> � - � � On the North Shore of Lake Minnetonka <br /> DATA PRNACY 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 /> l.icense 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 Iocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�� <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> �r�b )1� �. MA� � �12,�_� n� <br /> First Middle Last <br /> ��-� � �In��, RI�_ <br /> Address <br /> 012df� I�-�I�• �3 5� <br /> City State Zip <br /> '_�c f CI _c��r� ( <br /> Phone � <br /> r <br /> �i�` �\o <br /> I understand my rights as stated above. �� � �� <br /> l � � <br /> _ t � <br /> ��.�.,����:� - t� <br /> Signature . � ^ (� � <br /> �✓-� <br /> BUILDING&ZONING—d73-7357 • ADNItiISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSI;�IG <br />