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,r - F� <br /> ..-�-::a. ,� r ,: �i��� O� ����� <br /> � �, <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Officea <br /> � <br /> � - � � On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04 . �'�•bd. 2 , "Rights of subjects of <br /> data", we would like to inform yot- �t your request for a permit or <br /> license from the City of Orono or L 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 data, but refusal may require that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with other local , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or license requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�at� <br /> data on yourself. <br /> 6. Your full name is required to process this application or ' <br /> permit. <br /> G�/i��so� G.�/ns���'S <br /> Gv��-� !� �fo��`t��-z- <br /> First Middle Last , <br /> �/TS � /�✓Y �3� <br /> Address <br /> �7; l-fH�� /�1�✓ �S/D 9' <br /> City State Zip <br /> �d2-02o5 <br /> Phone <br /> I understand my rights as stated above. <br /> (�� Ur�2� � D �-n�s <br /> ignature <br /> BUILDING&ZONING—473-7357 � ADMINISTRATION&FINANCE —473-7358 • PUBLIC WORKS—473J359 <br /> ASSESSiNG <br />