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-� <br /> '.:-ry;�a;':,_� <br /> ¢ ��a x,�.�-r " <br /> � � r ,> F� <br /> , -��" � 4. �i��� �� ����� <br /> � <br /> d <br /> ^r.-.. � r� m. •:.�.v <br /> u�;m:�:Suc:�;�:::. Y�;s:.,:::��1 <br /> *-� � � *M" �.���� <br /> ^'�- ��x� Post Office Box 66•Crystal Bay, Minneaota 55323•Municipal Officea <br /> ;,��': � ��s� <br /> � - �g �> 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 request for a permit or <br /> license 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 require that <br /> the City deny the permit or ].icense. <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 /> �icense. <br /> 4. If your requested permit or Iicense requires Council action <br /> to approve, some information may become publ.ic. <br /> 5. You have certain rights under M.S. 13.04 �o review priva�� <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> � <br /> �",�l/'�'�C;,"'' � � �b'1 �'L�' ��� � � �� ���� �� <br /> First Middle Last . <br /> 55��� � /�� � ��.� �l�1�' _ <br /> Address <br /> ��� � � �,� .��;�3�'l I <br /> City State Zip <br /> ��7.�- 3� � � <br /> Phone <br /> I understand my rights as stated above. <br /> `��� �� � <br /> Signature <br /> BUILDING&ZONI[YG—473-7357 • ADMIlY1STRAT[ON& FINANCE—473-7358 � PUBLIC WORKS—473-7359 <br /> ASSESSING <br />