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, <br /> �;;�� <br /> ys� �� <br /> a <br /> r� ; `�, �' � !�,.. <br /> -- i .� ;:� , c�TY o� oR��vo <br /> 4 � � � <br /> „� r��"� A� <br /> '�' ' k ,`.;� Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> ,i,T ,z <br /> '�:�. � ;:��I <br /> '� • . � On the North Shore of Lake Minnetonka <br /> r�,w .;;::� <br /> �. � , <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data" , we would Iike to inform you that your request for a permit or <br /> Iicense 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 wil. I be used to determine your <br /> qualification for the permit or Iicense requested. <br /> 2. You may refuse to supply data, but refusal may rea,tiire that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other iocal , 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 Councii action <br /> to approve, some information may become public. <br /> 5. Yau have certain rights under M.S. 13.04 �o review pri�a�� <br /> data on yourself. <br /> 6. Your full name is reqciired to process this aorelica�icn o� <br /> permit. <br /> ---- <br /> ..�'�t,-.-� r � ���-��- � `-'�=�Z <br /> First Midd e Last <br /> � �l�� �- j ��'y ��C� u; <br /> Address <br /> C 2c.ru� rv�2 S �3 i/ <br /> City State Zip <br /> �(`J / �- S Z� �� <br /> Phone <br /> I understand my rights as stated above. <br /> ��,/C_i <br /> Sign� ure <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&F[NANCE —473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESS[NG <br />