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�n � <br /> >�, �. '�, <br /> =�� ����' �� ���1�T� <br /> , a <br /> �. <br /> - Post Office Box 66•Crystal Bay, Minnesota 5a323•Municipal Offices <br /> 0 <br /> _ s - a �j On the North Slzore 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 deoartments 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 rnay refuse to supply data, but refusal may reQuire that <br /> the City deny the permit or license. <br /> 3. The information may be snared with other i.oca '_ , s�a�e or <br /> federa� agencies to the extent necessary to process the permit or <br /> I.icense. <br /> 4. If your requested permit or Iicense requires Councii ac��o% <br /> to approve, some inrormation may become public. <br /> 5. You have certain rights under M.S. 13.0� to review Frivate <br /> data on yourself. <br /> 6 . Your full name is required to process this application or <br /> pe�-mit. � <br /> , J, . � <br /> ������ � � <br /> First Middle Las- <br /> � `I';�" ��- �J`� Y �� S �� �'�`✓, � <br /> Address <br /> c�",— --, � �/ <br /> ,��v� �,�J� 5' 1./`, . .J _� �j j:� <br /> City State Zip <br /> �r`� ! 7 � � �-� <br /> Phone <br /> I derstand my rights as stated above. <br /> � � � <br /> n ure . <br /> BUILD1vG& ZONftiG — 473-7357 • AD,�tINISTRATIOV& FIVANCE —473-73�3 • PUBLIC�VORKS —473-73�9 <br /> ASSESSIN G <br />