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�3.4�w/rc+�Y�n� '�.s�.� . <br /> � <br /> • �1j.eM <br /> !-4b � Is'i. '� <br /> �=������ CITY of OR011\T� <br /> �...Y ,��.. � ¢ <br /> ,� � � Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> 0 '�� <br /> . � _ � 7'".�`h On the North 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 like to inform you that your request for a permit or <br /> I.icense 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 /> l. The information you furnish wi3.I 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 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 Councii action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 �o rev�ew pri�a�e <br /> data on yourself. <br /> 6. Your full name is required to process this applica�ian or <br /> permit. <br /> ��i� �l��� � �l � �� �'.l'� �� �� �1 <br /> First Middle Last <br /> ��1 � � �1`�n.�l-C�:,� ��' l' - <br /> Address <br /> �-�"- '� ti '? t�'�1'� �'ln� ,. �5��3 �� � <br /> City State Zip <br /> �l �� � ' 3-� �f � <br /> Phone <br /> I understand my rights as stated above. <br /> � <br /> ,�:�� �����.-` - - <br /> Signature � <br /> BUILDING&ZONItiG - 473-7357 • ADMINISTRAT101& FItiANCE - 373-7358 • PUI3[,IC��'nRKS - 473-7359 <br /> ASSESSING <br />