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1 � <br /> 1 <br /> 4 <br /> . � ��1:Y;h <br /> .Cxai^� S+f <br /> �Rj+�� �d j�N i <br /> �y , :,�� `�,,, <br /> ��� CI�Y of O1i01'�T� <br /> . � �;:} <br /> ;�p&� r,'�x'x a � <br /> ,..� ;�.. � <br /> �'R�.�, �..,," <br /> �"��� Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> �� <br /> ��, . �� <br /> r4�,;>- <br /> � .� - � � � On the North Shore of Lake Minnetonka <br /> DATA PRNACY 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 /> 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 /> l. 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 Iicense. <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 /> Iicense. <br /> 4. If your requested permit or Iicense requires Council actior. <br /> to apprcve, some ir.fcrmarion may become pub3ic. <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 /> `->C tU T � �,�_%��1�%��l'_ (�j �.,'f..)l_-1 (_ <br /> First Middle Last <br /> �1 �2, � � 1������, '(;�(� �� I_�=' <br /> Address <br /> y����. ��,�i-� y�i;' '`� � ��°t�.v�„" <br /> t <br /> City State Zip <br /> t1 l ,� ` �- � L, <br /> Phone <br /> I understand my rights as stated above. <br /> Sj�,,.�.,��' �,��,�����,f�i�' %� � <br /> Signature <br /> BUILDING&ZOIYING-473-7357 • ADMIN[STRATION&FINANCE-473-7358 • PUBLIC WORKS -473-7359 <br /> ASSESSING <br />