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ti <br /> � � ���� o� ����� <br /> . Post Office Box 66•Crystal Bay,Minaesota Sa323•Municipal Offices <br /> N� . <br /> • _ <br /> On. the North Shore of Lake Minneton a <br /> • ' • � <br /> DATA PRSVACY ��SORY <br /> "Ri hts of subjects of <br /> In accordance with M.S. 13. 0� , Subd. � <br /> g �.. eZ"Iii1.t Or <br /> for a p <br /> data", we would like to iniorm you th f itsrdepartlnents may requ2re <br /> license from the City oi Orono or any �n=o�ation. <br /> you to furnish cer�ain private or confidential <br /> vou are notified that: <br /> 1. The inf ormati°n <br /> you furnisn wi1l be used to determine your <br /> cualificat�on for the pe'-'�i� or license reauested- <br /> 2. You may refuse to supoly data, but refusal may require that <br /> the ernit or 1�cense. <br /> tne City deny P . <br /> 3. The information may be snared witn ot:��=" local , s�a�e or <br /> f ederal agencies to the extent necessary to process the permit oi <br /> ?icense. . <br /> y per•nit or iice�se reQuires Council ac��or. <br /> a. �i your reques�ed become public. <br /> to aporove, some information may <br /> You have certain rights under M.S. 13.04 to review Briva�e <br /> data on yourself. <br /> 6 . Your ful.I. name is requ1red to procsss this application or <br /> pe�it. <br /> � �� � �'. <br /> CS� � u,'- Las� <br /> r^irst Middle <br /> � <br /> -� � / 2 /'��'��- 1����� i�/�-� r . <br /> � <br /> Addres s ^ � <br /> �- S��l �- <br /> i � � � �ti � .� - <br /> �='� r � <br /> -� �._� �� � ,, Zip <br /> City <br /> State <br /> �, -� � �, � � j <br /> Phone <br /> I understand my rights as stated above. <br /> _�,����� °� _ - <br /> Signatur�' <br /> � pDMINISTRA"IZON&FINANCE-473-7358 <br /> • PUBLIC WORKS-473-7359 <br /> 3UILDING&ZONING-473-7357 <br /> ASSE55IN G <br />