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� � <br /> � � .:: <br /> :.,� -�,,, �. <br /> -��.'�� <br /> ������ �,�.��`;-�.� <br /> � <br /> � � { ` (��'�`�' �� ��O�TO <br /> �.��.��...�_ ��, � <br /> �=�� �rf :A : <br /> ;� ��:a;�:;.,.,�.. <br /> �1 : r-' <br /> ��� Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> � �',�;�:���.'` <br /> • - • s 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 /> 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 /> 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 , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or 3icense requires Councis 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 process this application or <br /> permit. <br /> ��� � � �/� � ,.L;,���� <br /> First _ Mid Ie Last <br /> ���OL „�,4 �E �; � E �c.� �C i�f�•��-� <br /> Address � <br /> .��;,v 9 L,q .�r� /1�� /l.� `� _'� .-���, <br /> City State Zip <br /> y7� "73y � <br /> Phone <br /> I understand my ri s as stated above. <br /> �,/1 ���.�� ���'F -�,�`�� <br /> � � � " -�� -�_ <br /> Signature <br /> BUILDIVG&ZONING—473-7357 • ADMINISTRATION&FINANCE—173-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />