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�r t <br /> �"� ,,{',. <br /> �i � it��� "i� <br /> n,�� p <br /> � h <br /> � �� $� C ITY of ORON(� <br /> y T' �-- "' Si t sY �r� <br /> d� �; a � _ � ,�z�! <br /> ��-y�< ba+� � t� <br /> �°. �'����,_� Post Office Box 66•Crystal Bay, Minnesota 55323�Municipal Offices <br /> , Y,: _; <br /> yk<:: �: , i <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 yau 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 wiZl 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 Iicense. <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 Zicense requires Councii action <br /> to approve, some information may become pub.Zic. <br /> 5. You have certain rights under M.S. 13.04 Lo review pri�a�� <br /> data on yourself. <br /> E. Your full namP is required to process this apFlicatian or <br /> permit. <br /> �� -� <br /> � �'�c ��� � S�'-'r�����. --� <br /> First Middle Last <br /> r �� ��. <br /> �7> ���' ' � � � <br /> Address <br /> `�.'�'� � f���� �t,� , - <br /> Cit State �zP <br /> ��� - Z2z-f <br /> Phone <br /> I understand my rights as •�stated above. <br /> \ �� ' � i <br /> v� � !� ��--�. <br /> � � <br /> Si na ure , <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSIN G <br />