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;'"` � <br /> ��^'�IC ` <br /> . �� �'.�. 1 <br /> , yri� r <br /> �� � T_ . C�"��' �� O��lOT� <br /> ;r <br /> � ' Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> � <br /> � A _ � �; On the North Shore of Lake Minnetonka <br /> . <br /> � DATA PRNACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we would 3.ike 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 /> l. 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 Iicense. <br /> 3. The information may be snared with other local , s�ate or <br /> federal agencies to the extent necessary to process th� permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii ac��o% <br /> to approve, some information may become public. <br /> 5 . You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> , <br /> � � ''�-�`� ��L,� C 1 �^ ��,_ �� J\�' <br /> �, .�- � l 1 � <br /> First Middle . Last <br /> �iY='-�% f��� �L,� s� ��r i z-�- <br /> Address <br /> � , _��`� �j. <br /> C � r�--,�L�r�� ���-i J �v _�� <br /> City State Z1p <br /> l/ ?/ ` �'/`��/ <br /> Phone <br /> I understand my rights as st ed ab e. <br /> i. / %' <br /> _�. . <br /> //� �,_� :�' _ __ <br /> ignature . <br /> BUILDIVG& ZON[NG —473-7357 • ADDi1NISTRATION&FINAtiCE — 473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />