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R � • <br /> ~ �. 'n=J� <br /> �� _ � �, ., _._ �� ����� <br /> - � �.�� �..i��� <br /> ���t�r <br /> 01 : Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> s _ � o On the North Sh.ore of Lake Minnetonka <br /> DATA PRNACX 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 /> l. The information you furnish will 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 Iicense. <br /> 3. The information may be shared 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 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 ful.l name is required to proc�ss this application or <br /> permit. <br /> � <br /> ��/ �,�. � �Gl �'I � u � <br /> l <br /> � .�✓l���-.� � v N <br /> First <br /> Middle Last <br /> � � � � �j� ��� �� ���J <br /> Address <br /> �� c� �, ���'��S �� �5��� -� � <br /> City State ZiP <br /> ���- ��� �, <br /> Phone <br /> I understand my rights as stated above. <br /> % l%' - <br /> ;:�=; _ <br /> � <br /> Sign re � � <br /> i <br /> BUILDING&ZONING—473-7357 <br /> • ADMINISTRATIOIY&FINA[VCE--i73-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />