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s::^ <br /> ��T <br /> � �����,. <br /> �'"n �.���. � <br /> ���:� �f����-��� (���Y o� ���NO <br /> �.� � _�. <br /> � � r� <br /> �-- - ' � Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> �s� <br /> �,:�-�v.:-� <br /> 0 <br /> � _ e s On th.e North Sh.ore 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 3ike to inform you that your request for a permit or <br /> Iicense from the City <br /> 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 license. <br /> 3. The information may be shared with other Iocal . e�it or <br /> federal agencies to the extent necessary to process the p <br /> 1.icense. <br /> 4. If your requested permit or license requires Councii ac�ior. <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 proc�ss this application or <br /> permit. <br /> �7 / ��J d-�� �r-� <br /> � � � 6�<<r � � <br /> Middle Last <br /> First .- <br /> S i �'� / �/, �� k6 rE� Y/'l l,� � <br /> Address � <br /> �^�1���- ,-1 7'L� ���3��l <br /> City State Zip <br /> L/ �/- ��� 7 <br /> Phone <br /> I understand my rights as state ab�e. <br /> �� � � <br /> nature � <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 <br /> • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />