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_ .. � . <br /> � <br /> CITY of ORONO <br /> Post Office Box 66•Crystai Bay,Minneaota 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 like 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 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 /> license. <br /> 4. If your requested permit or Iicense 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�a�e <br /> data on yourself. <br /> E. Y�ur full namP is required to process this apglicatian o� <br /> permit. <br /> ��-e .17 � �.� ��}c��C3s o � <br /> First Middle Last <br /> �S�' � �' C�c.2 c o ,-� (�,..1 W1 f�� -Ir��-ti = <br /> Address <br /> ��Lt ��� � � � ����5� <br /> City State Zip <br /> I�I-T�� -C,�r� /� �-1�� �-7y- 7��-� C�-�-� <br /> Phone <br /> I understand)my ig ts as ated above. <br /> � <br /> / <br /> � <br /> Signature <br /> BUILDING&ZONING-473-7357 • ADMINISTRATIOti& FINANCE-473-7358 � PUBLIC WORKS -473-7359 <br /> ASSESS[NG <br />