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� <br /> � �'�Xi_� <br /> ��r �a,,;�'�.�':.,�i <br /> ��r� y�� F.. <br /> �"'4 �� �,.� x r�e � <br /> '�����-�- y�g�}�+ - C I'�7�' o� OR��' <br /> y.�� }� <br /> �'� 'a(��'��bT i <br /> '�����f ��^��. <br /> _�.# � .� Post Office Box 66•Crystai Bay,Minnesota 5a323•Municipal Offices <br /> :''�°����.. <br /> "�'���`. 9 .� <br /> � _ A �� On the North Shore of Lake�lfinnetonka <br /> DATA PRIVACY 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 /> 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 /> 1. The information you furnish will be uuested, determine your <br /> qualification for the permit or Iicense req <br /> 2. You may refuse to suppl.y data, but refusal may require that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with ��=ocesscthe p rmit or <br /> federal. agencies to the extent necessary to p <br /> license. <br /> 4. If your requested permit or Iicense blic res Councii actio*� <br /> to approve, some information may become p <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�� <br /> data on yourself. <br /> 6, yaur full name is required to process this applicatiaa or <br /> permit. <br /> ,-�„ <br /> ,. , � , <br /> , ��'�� t �— _ � L a s t <br /> First Middle <br /> . '� � �' ,� , -� <br /> Addr�s � � �, � <br /> --� �L` � �� '� <br /> City State Zip <br /> � �"-� �'�� - �; `Z.-�� I <br /> � <br /> Phone <br /> I und tand my right s st ed above. <br /> i <br /> � � � �� <br /> ��� �-��.�> �,� <br /> Signature <br /> BUILDING&ZONING-473-7357 • ADMIN[STRATIO`1&FINANCE-473-7358 <br /> • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />