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� ` <br /> ` �� <br /> � ��'�'�i' o� ����'� <br /> Post Office Box 66•Crrystal Bay,Minnesota 5a323•Municipal Offices <br /> 0 <br /> s • s � . On the North Shore of Lake Min.netonka <br /> DATA PRNACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we wculd Iike 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 confidentiaZ information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your <br /> aualification for the permit or license requested. <br /> 2. You may refuse to supply data, but rer"usal may require that <br /> the City deny the permit or license. <br /> 3 . The information may be snared with ot:�er 3.oca1, s�a�e or <br /> federal. agencies to the extent necessary to process the permit or <br /> I.icense. <br /> a. If your requested per,r�it or I.icense recuires Councii ac�io% <br /> to appzove, some infor.nation may become public. <br /> 5 . You have certain rights under M.S. I3.0� to rev_ew private <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> pe=-�mit. � <br /> � First Middle Las� <br /> Address <br /> City State Zip <br /> Phone <br /> I understand my rights as stated above. <br /> Signature . � <br /> BUILDING& ZOrIVG-473-7357 • ADSfINISTRAT10N&FI`!�YCE-473-73=3 • PUBLIC WQRKS -473•7359 <br /> ASSESSIVG <br />