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-"�E ,+ti <br /> �� � ���� �� ����� <br /> « _ . Post Office Box 66•CrYstal Bay.Minaesota 5�323•Munidpal Offices <br /> • <br /> On the North Shore of Lake Minnetoizka <br /> � _ � • . <br /> DATA PRSVACY ��SORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> our request for a permit or <br /> data", we Would like to inform you that y uire <br /> license from the City of Orono or any of its departments may req <br /> you to furnish certain private or confidential insormation. <br /> You are notified that: <br /> l, The information you furnish will be used to determine your <br /> qualification for the permi.t or license requested. <br /> 1 data, but refusal may require that <br /> 2. You may refuse to supp y <br /> the City deny the permit ar license. <br /> 3. The information may be snared withto p=oc sscthe permit °r <br /> f ederal agencies to the extent necessary <br /> ?icense. , <br /> a, If your requested permit or I.icense requ�res Council ac�=or. <br /> to approve, some information may <br /> become public. <br /> �, You have certain rights under M.S. 13.04 to rev�ew private <br /> data on yourself. <br /> 6 , Your full name is required to proc�ss this application or <br /> pennit. <br /> First <br /> Middle Last <br /> Address <br /> City <br /> State Zip <br /> Phone <br /> = understand my rights as stated above. <br /> Signature � <br /> � • PUBLIC WORKS-4�3-�359 <br /> gUILD[NG&ZONING-4�3•7357 • ADMINISTRATION dc FiN.�►NCE-473-7358 <br /> pSSESSING <br />