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, , • <br /> . <br /> � <br /> CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> � � � � 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 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 confidential information. <br /> You are notified that: <br /> 1. The information you furnish wil.l be used to determine your <br /> qua].ification for the permit or license 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, s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> I.icense. <br /> 4. If your requested permit or license requires Council act�on <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your full name is required to process this appZication or <br /> permit. <br /> !�L-��S� �, G�c��}i S v � <br /> First Midd3.e Last <br /> 1 �0 �� v � �/C2 �,2i�lC <br /> Address <br /> C ���N�-1-�tsS � r_) ►M � S53I � <br /> City State Zip <br /> 33� - �I�c�� ��`�-a`��o <br /> Phone <br /> I understand my rights as stated above. <br /> ��c (� - <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMIIVISTRATION Fc FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING • <br /> ; <br /> # <br /> � <br />