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.� ��1� ��'+� � <br /> ,_.�.__,�,_ <br /> �� � � o� ���1�� <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Niunicipai t�ihces <br /> • <br /> e � � � 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 Iike 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 wil.l 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 Iocal, state or <br /> federal agencies to the extent necessary tQ process the permit or <br /> license. <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:�. 13.04 to review pri�a�e <br /> data on yourself. <br /> 6. Your full na�:e is rsq��i�e� to process tnis applicaLion or <br /> permit. <br /> A��"�GtCt r�� ��(�� � <br /> First Mid�le Last <br /> ) o �O �i�c� C( u V l:�h b t/� �cL_�_ <br /> Address <br /> �-�-c9-v <br /> City State Zip <br /> �{�� �� ��� <br /> Phone <br /> I understand my rights as stated above. <br /> Si n ture � . <br /> BUILD[NG&ZONING—473-7357 • ADMINISTRAT10lY&FINANCE—�i73-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />