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� � <br /> � � � '��' O� O�iONO <br /> CI <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Mumcipal Qffices <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 /> Iicense f rom 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 /> 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 Iicense. <br /> 3. The information may be shared with oth=o e scthe permit or <br /> federal agencies to the extent necessary to p <br /> license. <br /> a, If your requested permit or license requires Councii ac�ior. <br /> to approve, some information may become public. <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 proc�ss this application or <br /> permit. <br /> ,� �� ��� �;v�r.�"�n <br /> First <br /> Middle Last <br /> �S�t s 1 S- i� (�"� S <br /> Address <br /> � � �s`�t z3 <br /> 2����`c� z�p <br /> City State <br /> � �� �331 <br /> Phone <br /> I understand my rights as stated above. <br /> Signatur <br /> BUILDING&ZONING-473•7357 • ADbtINISTRATION&FINANCE-473-7358 <br /> • PUBLIC WORKS-473-7359 <br /> ASSESSING , <br />