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.� . <br /> «�e� <br /> �,,,,F 'r �� �.... _:� <br /> a i <br /> Y a , ° <br /> :� �� ';, ,� <br /> , ; <br /> � GITY of OI���TO <br /> �: 5 <br /> � ��, � <br /> }� � ��:y <br /> � �,._x �,� Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> � �;� <br /> � � i'~,� �'' 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 3ike 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 /> 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 Iicense requires Councii action <br /> to approve, some information may become publ.ic. <br /> 5. You have certain rights under M.S. 13.04 to review priva�� <br /> data on yourself. <br /> 6. Yaur full name is required to process this application or <br /> permit. <br /> � C <_ <br /> C� �3�LI ��L l.�k�.h <br /> First Middle Last <br /> ��G � 1���c. i�l�� - <br /> Address <br /> r� no ' �� � <br /> City S ate Zip <br /> �CP�� ) '�7/- G0�5 <br /> Phone <br /> I understand my rights as stated above. <br /> . � <br /> gnature <br /> BUILDING&ZONING—473-7357 • ADMIN[STRATIOti&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />