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r _ � <br /> , ,���y + 7 ;�!h <br /> J <br /> 'lE} . <br /> � �'� (�I'�'Y o� OROl�T� <br /> j p <br /> }�� <br /> `���°''���'= �,��, <br /> �^r�y� y^ <br /> �����;7i <br /> .�_;;�t. Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> z�„s.=.:7". <br /> :����L • <br /> ;-�yn:. �; <br /> �- a -`�o o On the North Shore of Lake Minneton a <br /> DATA PRNACY ADVISORY <br /> In accordance with M.S. 13.04 , Subd. 2 , "Rights of subjects of <br /> data" , we would I.ike 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 wi3l 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 i.ocal. , 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 public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�e <br /> data on yourself. <br /> 6. Y�ur full name is required to process this apr-Iicatian o� <br /> permit. <br /> � � � , <br /> .l � �� �� � �� �1 � �� l c' 1�� �r <br /> First Middle Last <br /> ) >>� •` , �`���'�..�� ��' ( <� r. � ,'� L, . <br /> Address <br /> _ <br /> � � � <br /> �__ -� � >/t- �, f L�( J�; � ', C' <br /> City State Zip <br /> <�' �� �( (� �� � �° �--<'���1 `� C;.�. t-i <br /> (<' / " <br /> Phone <br /> I understand my rights as stated above. <br /> � <br /> � j �,, <br /> ` � � � � � <br /> Signature <br /> BUILDING&ZONING—4�3-7357 • AD!�iINISTRATION&FINANCE —473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />