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` �� � j. <br /> UTS ytqqW`j, �`yg�ir'dr; <br /> t's <br /> ���� .�ap �-�x x C ITY o� ORON <br /> �-��, ��+,�; <br /> tisAd ':•Ts�T':�i�"`Kye ' <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•MumciPal��� <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 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 /> ycu to furnish certain private or confidential information. <br /> "�u are .^.otifi^� t;��t; <br /> l. 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 license. <br /> 3. The information may be shared with other local , s�ate 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 ac��or_ <br /> to approve, some information may become public. <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 proc�ss this application or <br /> permit. <br /> (�-- — � I � � . <br /> First Ni�ddi� Last <br /> > � �v ,� �: <br /> �� �C>G^ � � �-_ <br /> ; <br /> Addres <br /> ' � �� ���3 I <br /> ��L� �, � � c r� C� <br /> City State ZiD <br /> � � l �G'��o � - <br /> Phone <br /> I understand my ri ts as stated above. <br /> �_�f' <br /> , r V`�' <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE —473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSIN G <br />