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` , � <br /> � <br /> C ITY of ORON� <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> � _ � � On. the North Shore of Lake Minneton.ka <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 information. <br /> You are notified that: <br /> 1. The information you furnish wi13 be used to determine your <br /> qualification for the permit or license 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 /> license. <br /> 4. If your requested permit or 3icense requires Councii action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�ate <br /> data on yourself. <br /> 6. Your full name is required to process this applicatioa o� <br /> permit. <br /> �)���{'��� � -�� L�f��1,'�o/� <br /> First Midd3e Last <br /> ��'..�'r, �- <br /> ���-L� �C� c. � ��'1 <br /> Address <br /> � � <br /> 'L��,�ci ���� � �'� ���> � �5 , <br /> City State Zip <br /> 4���-- S� �- � <br /> Phone <br /> I derstand my ights as stated above. <br /> .I 42 •� '�� <br /> S ' n ture � <br /> � <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION�FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSFSSING ` <br />