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1 <br /> t CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> � - � � On the North Shore of Lake Minnetonka <br /> DATA PRNACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we would 3.ike 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 suppZy 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 /> I.icense. <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 private <br /> d�ta on yourself. <br /> 6. Your full name is required to process this appl.ication or <br /> permit. <br /> �c�1>>l '�1zotV E�3 �v�p y Ti2otV�'--� �4N s�'-. <br /> First Middle Last <br /> �Zl O� 1�0{� �!� _S . <br /> Address <br /> �t 1�� C�C' l�t • S�`l 3 S <br /> City State Zip <br /> �Zc-�3s3. <br /> Phone <br /> I unders d my rights as stated above. <br /> Signa ure <br /> BUILDING 8c ZONING—473-7357 • ADMINISTRATION 8c FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />