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i R. J6 ��' �' � � ' <br /> i T),} �i]� h . <br /> ii � �,5 �D H }..'- <br /> �� '� � '` � GITY of ORONO <br /> ��,�,-�y;'�;�'��,.-�;�� �. <br /> Post Office Box 66•Crystal Bay,Minnesota 55323�Municipal Offices <br /> e <br /> � - � � 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 like 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 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 3ocal, 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 /> /'��`�����/;� � �'�� �i '�-s <br /> First Middle Last <br /> � �. <br /> ����� ��/G�� /./J��J� /) � - <br /> Address <br /> � % —,.-:-- �� <br /> �`!/,y���:���7/� :1�/��/% -='�: ..' �- - <br /> City State Zip v <br /> ��%� �-=,%���'�� <br /> --� <br /> Phone <br /> I understand my rights as stated above. <br /> /� --�- � <br /> /. �' =�' � �� � <br /> Si ature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />