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�,,�� �.i��s} . <br /> 7 �9 j <br /> ��.;�.�, <br /> z}` �- C I'��' Of �R�NO <br /> ..�... <br /> > ;�� �� <br /> �'"'M, �'`''` Post Office Box 66•Crystal Bay, Minnesota a5323•Municipal Offices <br /> • <br /> � . � � On the North Shore of Lake Minnetoraka <br /> DATA PRNACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we would Iike to inform you that your request for a permit or <br /> Iicense 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 data, but refusal may reguire that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with other iocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Counci� action <br /> to approve, some information may become publ.ic. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�e <br /> data on yourself. <br /> 6. Your fuZl name is required to process this application or <br /> permit. <br /> ' � �.� d�L�,� <br /> f� ►�a �;� ; � Er�.�� <br /> First Middle Last <br /> � '� '��1 v � i�k� ,� �� N��--- <br /> Address <br /> �!. �'G t� ;"�IV" _5�' "�'�`/ <br /> City State Zlp <br /> j �, I �-.� _��' '7- ,� �{ 1 j� -- <br /> Phone <br /> I understand my rights as stated above. <br /> ;-� <br /> .i� � , %� <br /> Signature / <br /> ' <br /> BUILDINC&ZOVING—473-7357 • ADMINISTRATION&FINANCE—373-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />