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� �� • ,� ✓ <br /> 5 <br /> '��7 <br /> s�- CITY of ORONO <br /> � <br /> � Post Office Box 66�Crystal Bay,Minnesota 55323•Municipal Offices <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 /> 1.icense 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 supply data, but refusal may require that <br /> the City deny the permit or license. <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 /> license. <br /> 4. If your requested permit or license requires Councii actiar. <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to rev�.ew priva�e <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> 1������� 2 � /�� I�N�-T c���: 1/ <br /> First Middle Last <br /> � �- �'J �01�► a �_ ►"L1 c� �� � V �_ - <br /> Address <br /> ��'"� C E.,1 vl �f h'� �1 ��..i �L <br /> City State Zip � <br /> J �. ' � 1 <br /> `� 7/ -�� 4 7: l�-� �'7� -) � <br /> Phone <br /> I understand my rights as stated above. <br /> r� <br /> �c ��%?�� ,�.� `C' 1:4 �1�.�'� <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESS[NG <br />