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r � <br /> x,�`t,,'�� <br /> �����'�'��,IF� : : - <br /> '�'� �� � i 1 r�r�,�;. <br /> =�a� � ��� t a (�I'��' O� ��(��T'� <br /> ,� ,� , ., <br /> ��. �t,�«;x,�� �a- <br /> ����� Ad 3 ��+' Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> ��,�>��;�� <br /> �� �;. ;� <br /> �-`}' On the North Shore of Lake Minnetonka <br /> ;'� m - e • <br /> s <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 ctata, but refusal may require that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with other �ocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or 3.icense reauires Councii action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review prica�� <br /> data on yourself. <br /> 6, Your full name is required to process this applicaticn o� <br /> permit. <br /> .� �-,- <br /> First Middle Last <br /> _ ��- � <br /> Address <br /> �-�c� � a���.5�--� <br /> City State Zip <br /> `�73 - 8'�.2� <br /> P�one <br /> I understand my rights as stated above. <br /> Sign ture � <br /> BUILDING&ZONItiG—473-73�7 <br /> • AD!HP•YISTRATION&FINANCE—473-7358 • PGBLIC WORKS —473-7359 <br /> ASSESSING <br />