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i <br /> � <br /> i <br /> � � ���� �� ����� <br /> Post Office Boz 66•Crystal Bay, Minnesota 5a323•Mun.icipai Offices <br /> ♦1! <br /> � On the North Shore of Lake Minnetonka _ <br /> � - • • <br /> DATA PRIVACY AD�SORY <br /> Subd. 2, "Rights af subjects of <br /> In accordance with M.S. 13•ou`that your request for a pe="�it or <br /> data" , we would like �o inform y o f its departments may rea_uire <br /> license from the City of Orono or any <br /> you to furnish certain private or conridential iniormation. <br /> you are notified that: <br /> 1, The inTormation you furnish wil.l beeQuea�Pd, determine your <br /> cuali�icatiorl for the pe='ln=-� �r license <br /> Z data, but res"usal may require that <br /> 2. You may refuse to supp y <br /> tne City deny tne permit or license. <br /> be snared with other local , s�a�e or <br /> 3 . The information may to process the permit oi <br /> f ederal. agencies to the extent necessary <br /> Iicense. • <br /> q. 1i your recuested permit or <br /> Iice*:se requ�res Councis a��'-dr <br /> ation may become public. <br /> to aporove, some insorm . • Vz�e <br /> J � <br /> You have certain rights uncier M.S. 13. 04 to rev�ew pr= <br /> data on yourself. <br /> L ' or <br /> 6 . Your full name <br /> is rec-uired to p,-oc=ss t�is apolica �-on <br /> pe�i�. <br /> � '`�'�-1� <br /> ��� � �� <br /> biiddle <br /> Las� <br /> r irst � <br /> 2� �� �SL,�,-�_�� `��j �� <br /> Address <br /> � ,�� , .� L �k � ' 7� SS `�`� <br /> — State Zip <br /> City <br /> � 7 � �� �� <br /> Phone <br /> = unde sta�id my rights s stated above. <br />�: . <br />� � � � � . <br /> Signature <br /> � pDMINISTRATIOiV&FINANCE--�73-�358 <br /> • PUBLIC WORKS-473-7359 <br /> SUILDING&ZONING-473-7357 <br /> ASSESSIN G <br />