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"�l - � <br /> ����e i� <br /> _ �_�Y.jy','4x���., �fi.A �� <br /> .,����,�4 CI'��' O� �R� <br /> ��- . . -��_ <br /> �� � • Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> s ' • o 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 /> l. 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 snared with other Iocal , s�ate 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 ac��or. <br /> to approve, some inf ormation may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�e <br /> data on yourself. <br /> 6. Your full name is required �o process this application or <br /> permit. <br /> ' L�� <br /> � _ <br /> , �;� � , �� �;�.�.r�Z------ <br /> ,���< <-+��-�c-ti�� �i� t-�7 <br /> First1� r Middle Last <br /> Z��-��? �� �- l i i�- l�-t�, <br /> Address <br /> �� � � (-�� � L• l l <br /> _��{-�. 1�r.�� �'�l� �-� � -� - � -� <br /> City State Zip <br /> �t �� _ �� i L��� � <br /> Phone <br /> I understarld my righ s as stated above. <br /> , , <br /> � ��� .1,A,���, ����� �--�� <br /> ; � � <br /> Signature__ . � <br /> BUILDI'YG&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSIN G <br />