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4 �,h f <br /> g �4� <br /> -�! xi-Qi�l��_,...ak.f';4*ej'. <br /> tr,ew:�a::� '+�A" # a4� .:" <br /> ����.9 ��. Ci I�� O� ����� <br /> 'x� ��Y t r �s+, ., <br /> � <br /> a ew,�g�'5�"u...t.,�" <br /> P''��. <br /> `"= � ` Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Officea <br /> • <br /> ,� - � ,� On the Nortlz Shore of Lake Minnetonka <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 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 iocal , state 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. 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 /> /"�T�'/� -Z �c..�S�,C/ <br /> r <br /> First Middle Last <br /> ��..._�S" r',r �� <br /> Address <br /> .���� /'�iv S`.���s� <br /> Cl State Zip <br /> 5'�� �t'ra <br /> Phone <br /> I understand my rights as stated above. <br /> � <br /> �✓ - ,�'�� <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br /> � <br />