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. <br /> � <br /> GITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minneaota 55323•Mnnicipal O�cea <br /> • <br /> � - � � On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADAISORY <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 will be used to determine your <br /> qualification for the permit or Iicense requested. <br /> 2. You may refuse to suppl.y 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 priva�e <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> �o�� ��r' � L�'��=3 _ <br /> First Middle Last <br /> y� o L►'�d��, ,q-u � <br /> Address <br /> �''L �t�� �/1 /V �,�, � �5�� <br /> City State Zip <br /> �� 2- �7� ._ o�-z y� <br /> Phone <br /> I understand my rights as stated above. <br /> Sig a ure . <br /> BUILDING&ZONING—473-7357 • AD!NL�IISTRATION&FINAIVCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSiNG <br />