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� r� <br /> ��'J.- <br /> ""�" ' i°��, -.�..._, <br /> �,�W r . <br /> r ,:a..:'�.,t.���. . <br /> ` CI'�Y O� 0��1�T� <br /> � ;, �,z . <br /> a � A ,. <br /> 1 �3� ��� �� ;�r 7 <br /> ' ` ;�,�_ ,,,,' Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> < � <br /> -?�'� � �; � <br /> e�. � <br /> F'''���' r �''` ' '' On the North Shore of Lake Minnetonka <br /> � - � � ` <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 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 will be used to determine your <br /> qual.ification 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 snared with other local , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Council actior. <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 process this application or <br /> permit. <br /> 'Y`��c` I���H��i.i� e�,t� `��cax <br /> First Middle Last <br /> Z�,�'�" F� � �� <br /> Address <br /> Y, . \! ",1 �i ��� ��%� 1 yl., .��7� <br /> City State Z1p <br /> �aJ� _ �'t� /�'. <br /> Phone <br /> I understand my rights as stated above. <br /> ��f <br /> � <br /> '�j __�=�'i'�-.� <br /> Signature, ` / %� I <br /> BUILDING&ZOIYING—473-7357 • ADMINISTRAT[ON&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />