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at� _�_e9 "r'_. <br /> Lc',K}2n i.� r <br /> �.�1i� �� �„� <br /> ��.�,�� �`�" - CI'��' Of OR�l'�T� <br /> a �_ �;��� �,.;. <br /> ;Ra��..��."r�.�:�ti�"�. <br /> "�'�'"�� '�"'--' Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> )1 <br /> ' - � y 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 3ike to inform you that your request for a permit or <br /> license f rom 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 Iicense 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 local , state or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Councii ac�ior. <br /> to approve, some information may become pub3.ic. <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 /> (1���-1 R�L � . ��N 1V E Y <br /> S��zr� .7. S. F►NNEY <br /> First Middle Last . <br /> ,�}I cT S H t C;-H��j C�G.(� (�C�Fl C� <br /> Address <br /> �Ror�;o n,�rv �5 3 t�4 <br /> City State Zip <br /> ��2 4�z c��1to3 <br /> Phone <br /> I understand my rights as stated above. <br />, �_. c -.�.— S ' �� �� C � L� S.N— � v''i--`c'�_ r_/ �'_Y/ <br /> j 4 <br /> Signatur . <br /> „ _ <br /> BUILDING&ZOfYING—473-7357 • ADMINISTRATION&,FINAtVCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />