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� . <br /> CITY o� ORONO <br /> Post Office Box 66�Crystal Bay, Minnesota 55323•Municipal Offices <br /> • <br /> � - v � 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 Iike to inform you that your reguest 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 confidentia3 information. <br /> You are notified that: <br /> 1. The information you furnish wi3.1 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 , 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 act�or. <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to rev�ew private <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> L=� > ,_ -�y' � _ - � l �.- -t c C- /L <br /> First Middle Last <br /> �; :� ;�� ;- ( r f,_�= . , }� � f l �� j 1 <br /> Address <br /> � �. <br /> � i���� ���.��'� c -7�., 2 ��% ' -� � <br /> i <br /> City State Zlp <br /> ` � <br /> � � _ � �,,� :� , <br /> Phone <br /> I understand my rights as stated above. <br /> � �j: <br /> ; j � <br /> `/- ,� --�����__ l ,%�'���� <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATIOIY&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />