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� �; <br /> °�, '� .,.���, :� ,,�, <br /> �� .�.�p <br /> �4 � � ��. CI'T''�' Of O�i010T0 <br /> � ; _ <br /> L '� �� ��� ; � � <br /> � � t� ,� ,� Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> E�t� .:3��� ;� � ,: <br /> 5 �° - ,� � -: On the North Slzore 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 /> 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 snared with other 3.oca1 , s�.ate or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or I.icense requires Council actior. <br /> to approve, some information may become pubZic. <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 process this appl.ication or <br /> pe�-mit. <br /> �I ,�-v� � ��I�;�-�� , <br /> First Middle Last <br /> ��2�' G��V�� --1�'t�.�--' <br /> Address � <br /> �, ��s ,��-�,�x�- �� �� 3 � <br /> City State Zip <br /> ��� 113 <br /> Phone <br /> I derstand y rights as stated above. <br /> . <br /> S ' ature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBL(C WORKS —473-7359 <br /> ASSESSING <br />