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� K <br /> I <br /> CITY of ORONO <br /> Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> 0 <br /> � - � � 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 /> l. 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 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 Council. action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�� <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> �.(��c�� �-►;�. <br /> First Middle Last <br /> � 4.�1f� `f �r� S �� <br /> Address <br /> �.�r ! iLl '✓�'1.A.' �S3� `I <br /> City State Zip <br /> y 9�- �9C� <br /> Phone <br /> I understand my rights as stated above. <br /> a� <br /> i nat e � <br /> BUILDING&ZONING-473-7357 • ADMINISTRATION&FINANCE-473-7358 • PUBLIC WORKS -473-7359 <br /> ASSESS[N G <br />