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. s ti <br /> �� - <br /> _ �-__�: - •4} " <br /> �� ��'��.' o� ���.�T� <br /> t � <br /> �� Post Office Box 66•Crystal Bay, Minnesota 5a323•hlunicipal Offices <br /> 0 <br /> : � - a gr On the North Shore of Lake 11�iinnetonka <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 /> Iicense 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 /> l. The information you furnish wil.l be used to determine your <br /> qualiiication for the pe?-mit or Iicense recuested. <br /> 2. You raay refuse to supply data, but re=usal may reQuire that <br /> the City deny the permit or I.icense. <br /> 3 . The information may be snared with o`�er iocal , s�a�e or <br /> f ederal agencies to the extent necessary to process tne pe�-mit or <br /> license. <br /> 4. If your requested per.^it or Iicense =ecuires Councii ac��o% <br /> to a�Drove, some infor:Ttation may become pu��.ic. <br /> 5 . You have certain rights under M.S. ?? .C� to rev;ew pri-r��e <br /> data on yourself. <br /> 6. Your full name is required to process this applicatior. or <br /> pe�-mit. <br /> (�1����'`z-- 4�� ��.� <br /> F?rst Middle Las� <br /> )�3)� �����n-«:..�- �.�-� <br /> Address <br /> �i����r�,.�xra /ll�-� �;��i`3 <br /> City State Zip <br /> ����� `�� <br /> Phone <br /> I unde;stan m ights stated above. <br /> ,�� � <br /> '' �" c_:.1 <br /> �, <br /> Signature . <br /> BUILDI�G& ZO�'i�'G - 473•73�7 • AD,`i(:VISTRATION& FIVANCE - 173-73:3 � PUBLIC WORKS -473•73�9 <br /> ASSESSiV G <br />