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. _[N:,:'ar i. <br /> �s{ ''� +�.- <br /> �; <br /> 1� ���-- <br /> •� s� �. �z��.: <br /> "" �� ��� �` CITY of OROl�TO <br /> _ , �� ����� <br /> � -M � <br /> y i� <br /> � `��� �' �''� Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> �. ,:.t �.,.� <br /> • ���,,,. <br /> a,�<� <br /> s _ v � 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 /> 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 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 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 3icense requires CounciZ action <br /> to approve, some infarmation may become public. <br /> 5. You have certain rights under M.S. 13.04 to review privat� <br /> data on yourself. <br /> 6. Your full name is required to process this applicatian or <br /> permit. <br /> �r�t��-1 L E F-�1 /� . ���c'C�� <br /> First Middle Last <br /> � s�'�'y S�� /`� Z��2c— r�c:,.�-r� <br /> Address <br /> (,�..i��H Z.�+ �t--r-� �t.tv S� ��� <br /> City State Zip <br /> `-I� �C,`��s' .�7 � <br /> Phone <br /> I understand my rights as stated above. <br /> ���..0 L_ ��; �f �- - <br /> Signature <br /> BUILDING&ZO[YING—473•7357 • ADMINISTRATION&F[NANCE —473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />