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�iC�� r� �'• ...7' <br /> �� �`� �� CITY o� URONO <br /> �:-r;��'` <br /> Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> • <br /> • - e s On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we would 3.ike 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 confidentiaZ 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 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 /> license. <br /> 4. If your requested permit or Iicense requires Council act�or. <br /> to approve, some information 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 to process this application or <br /> permit. <br /> � �5���.,��� . <br /> � <br /> Fir t Middle Last <br /> � � ��� y.� �,��� /�,,� l��� <br /> Address <br /> �f / / C <br /> �✓(� , � �,:.-� /" �/IJ 5 ,S . 4� � <br /> Cit State Zip <br /> [ol Z 7 � Y — _� T �� <br /> Phone <br /> I understand my rights as stated above. <br /> � �� --� <br /> Sign ure <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&F[NANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />