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� <br /> �r <br /> �`'�- ��; <br /> _� r <br /> �� �"� �;} � <br /> � ����{ � � CITY � OR NO <br /> � � �� o O <br /> � ¢ : , <br /> � �. � �� �� <br /> ���. <br /> .�.���..�.:.�� .�. : . <br /> �h�', -� Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> 9 ,,,.,�;�x�� <br /> � - 0 *��'�'} 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 wi3.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 Iicense. <br /> 3. The information may be snared with other local , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Councii act�or. <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to rev;ew private <br /> data on yourself. <br /> 6. Your full name is required �o process this application or <br /> permit. <br /> P '., ,� ii �--1� �i `y� ` ,r� J'� �;� ��' � - - <br /> First Middle Last <br /> , � , <br /> � '� � � 1!, �.._' i�- ���( - <br /> Address <br /> i r <br /> i� j' ` �' � % — <br /> � L e;/ �� �' > E, <br /> City � / State Zip <br /> ;f � �� �. <br /> Phone <br /> I understand my rights as sta£ed above. <br /> � � , e <br /> � ._ '. c '� � a-C �-e <br /> Signature <br /> , <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />