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• , . <br /> - :�<�,°. <br /> ���.,. �-r <br /> �..�-. �- <br /> r+��a,.w-� 'R^� <br /> 1a, <br /> i����%�y. ���� <br /> ,�� �h M�- �� Ci��� O� � <br /> �..�,:�'� ���? -a <br /> �:. <br /> ��,,._,< Oi . '�`'-_���-�;� Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> - .�Y:tYWX:.� <br /> - >;, , ,�.s ;F',; <br /> e _ � �j 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 3ike 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 /> l. The information you furnish will 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 , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or I.icense requires Councii. act�or. <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 fu1.I name is required to proc�ss this application or <br /> permit. <br /> � <br /> �� ---> <br /> ��> �-r--� J � ,���"t ,�'E} <br /> ` Middle Last <br /> First <br /> �7 i � 4C � �-�� �� � <br /> Address <br /> /',, ���. �7�J -P� C> > <br /> City State <br /> 7 Z I- Z-S`�J-S� <br /> Phone <br /> �i �� <br /> I understand my rights t}ated above. <br /> � <br /> Signature � � <br /> ( <br /> BUILDING&ZONING—473-7357 <br /> /• ADMINISTRATION&FINANCE— 473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />