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� 4 �. <br /> � / <br /> 1 <br /> � - - CITY of ORONO <br /> Post O�ce Box 66•Crystal Bay,Minneaota 55323•Municipal Officee <br /> • <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 like 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 /> 1. The information you furnish wi3.I 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 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 license requires Council action <br /> to approve, some information may become publ.ic. <br /> 5. You have certain rights under M.S. 13.04 to review pri�at� <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> i���G��" � � �o �4 �� <br /> First Middle Last <br /> �'� 8 S L �`�-r � p �l �'!J�" <br /> Address <br /> �`- � �.- � lc ��� � �'s� 3 s9 <br /> City State Zip <br /> ��� 3 � � s- � <br /> Phone <br /> I understand my rights as stated above. <br /> Signature . <br /> BUILDING 8c ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING , <br />