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� � <br /> ' � ����' o� ���11T0 <br /> Post Office Box 60•Crystal Bay, Minnesota 5�323•Municipal Offices <br /> H� � . <br /> � On the North Shore of Lake Minnetonka - <br /> • - • • <br /> DATA PRNACY ��SORY <br /> n hts of SubjeCts of <br /> 13.04 , Subd. 2� R1g ermit or <br /> In accordance with M.S. our request for a P uire <br /> data" , we would like to inf orm you th Q f its departments may req <br /> license from the City oi Orono or any <br /> Y <br /> ou to furnish certain private or conii dential in�ormation. <br /> �ou are notified that: <br /> The inzormation you furnis?i ense�requested, aetermine your <br /> 1• e*-�nit or <br /> cualification for the p uire that <br /> refuse to suppl.y data, but re=usa� maY req <br /> 2. You maY e�i� or license. <br /> the City deny tne p <br /> be snared w�th oth�Y local , s�ate or <br /> 3 . The information may <br /> rocess the permit oi <br /> f ederal agencies to the extent necessary to p <br /> license. <br /> Iicense requ�res Councii a�-=°r <br /> a. I� your requested Per:nit °r ublic. <br /> to apvrove, some information may become p <br /> - You have certain rights under M.S. 13.Oa to review priva�e <br /> J • <br /> data on yourself. . <br /> � <br /> -ocsss this appl-ca��or. o <br /> 6 . Your ful.I name is required to P� <br /> pe�it. <br /> % , 1��- <br /> -� � � � � Last <br /> Firs� <br /> Middle <br /> 4 '� <br /> �-'j r � � i <br /> Address � <br /> ��� �y� _ _ <br /> � � State Zip <br /> City <br /> � � <br /> , <br /> Phone <br /> I understand my rights as stated aba�e• <br />'_3 , . <br /> � <br />� Signature <br /> i <br />� � pUBLIC WORKS -473-7359 <br /> I BUILDING&ZONING-473-7357 <br /> • aDMpYig-�FtpTIpN&FINANCE-;73-�358 <br />{ pSSESSIN G <br /> I <br />� <br />