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X <br /> . � <br /> ,; <br /> �� � ��t��" o� ��►��TO <br /> . Post Office Box 66•Crysial Bay,Minnesota Sa323•Munidpal Offices <br /> « ..K:�s- <br /> • - _ <br /> On the North Shore of Lake Minneto a <br /> � - � • <br /> DATA PRSPACY AD�SORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> ou that your request for a permit or <br /> �*_-• <br /> data", we would like to inform Y tif its departments may require <br /> license from the City oi Orono or any ' ;n=o�ation. <br /> you to furnish certain private or con=idential <br /> You are notified that: <br /> l, The information you furnir Zi ensebrequested, aetermine your <br /> aualification for the p <br /> er•nit o <br /> 2. You may refuse to supply <br /> data, but refusal may require that <br /> tne City deny the permit or license. <br /> 3. The information may be shared W=thto processcthe pern�it °r <br /> f ederal agencies to the extent necessary <br /> license. <br /> d. If your requested perntit or Iicense requ.i.res Council. a��=or <br /> to approve, some information maY <br /> become public. <br /> 5. You have certain rights under M.S. 13.04 to review grivate <br /> data on yourself. <br /> 6, Your full name is required to proc�ss this applicat�,c�n or <br /> pe*-�it. <br /> M' e <br /> ` � a s t ��`Y�9--�� <br /> First <br /> � � <br /> Address � <br /> �<-.��`� Z ip <br /> City Sta <br /> ,��� �41 <br /> Phone <br /> � . \ ri hts as stated ove. <br /> ` I unde tand my g . <br /> / ' . <br /> / ' - <br /> Signature � • <br /> -----. 473-7359 <br /> � • PUBLIC WORKS- <br /> BUILD[NG&ZONING-473-7357 • ADMINiSTRATiON&FINANCE-473-7358 <br /> pSSE55ING <br />