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�- <br /> �- <br /> �� <br /> -� C���'o� O�►��TO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> 0 <br /> s - � v 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 like 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 /> yau to furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your <br /> qualification for the permit or 3icense 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 inf ormation may be shared with other loca 1, s�ate or <br /> f ederal agencies to the extent necessary to process the permit or <br /> I.icense. <br /> a. If your requested perntit or Iicense requires Councii ac��on <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. Z3.04 to review priva�e <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> (� � i <br /> ��l�c e� U �-f, <br /> First Middle Las� <br /> �� " i IJQ�r � 0� <br /> � <br /> Address <br /> T�,�� r��, s5^C��iD <br /> City State Zip <br /> ��/4 -535' � <br /> � <br /> Phone <br /> I understand my rights as stated above. <br /> � <br /> Signature . <br /> BUILDING&ZOyI�IG—473-7357 • ADSIINISTRATIO[V&FINAYCE—473-73:3 • PUBLIC WORKS —473-7359 <br /> ASSESSIYG <br />