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. � <br /> j- - ��'��.' �� ����T� <br /> Post Office Box 66•Crystal Bay,Mianesota�5323•Muniapal Omces <br /> � <br /> � _ o � On. the 1�Iorih Shore of Lake ��linnetonka <br /> DATA PRNACY ADVISORY <br /> In accordance with M_S. 13.04 , Subd. 2, "Rig:�ts of subjects of <br /> we would Iike to inform you that your request for a per:rcit or <br /> data" , uire <br /> license from the City of Orono or any of its departments may req <br /> you to furnish certain private or confidential intormation. <br /> you are notified that: <br /> 1. The inrormation you furnish will be used to determine your <br /> qual.ification for the pe�:nit or licer.se requested. <br /> 2, You may reiuse to suppl.y data, but refusal maY require that <br /> the City deny the Ferm'-t °r Zicense. <br /> 3. The iniormation may be shared with other Ioca?, sta�e or <br /> federal. agencies to the extent necessary to process the pe="�it °r <br /> Iicense. <br /> g, If your reauested per.nit or license requires Councii action <br /> to approve, some inf or•nation may become public. <br /> 5, you have certain rig <br /> hts under M.S. Z3.04 to rev�ew p�ica�� <br /> data on yourself. <br /> 6, yaur full name is require� to process tnis appi ica�ic� oi <br /> permit. <br /> � �,r�� �--Z` 5 � -�fZ k 1�S'z <br /> First <br /> Midale Las� <br /> S-S �- � 1.� M � t�2. <br /> Address <br /> ��� w� �J SS 3 S'� <br /> City <br /> State Z�p <br /> 6�2.. �+ 7 S - I � �J.- <br /> Phone � <br /> I understand my rights as stated above. <br /> � <br /> � � . <br /> Signa ure <br /> BUILDING&ZONiNG—473•7357 • AD!NINISTRATj�y 8c FI`Y`�'�CE—;�3-7358 <br /> • PUBLIC ti`/ORKS —473-7359 <br /> ASSESSING <br />