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.7 . <br /> 1 <br /> -� �.:,� - <br /> - C���' o� ���I�TO <br /> � ' oi Post Office Box 66•Crystal Bay,Minnesota 5a323•Municipal Offices <br /> 0 <br /> � _ � ' On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04 , Subd. Z, "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 /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> l. The information you furnish wil3. be used to determine your <br /> qualification for the permit or license requested. <br /> 2. You may refuse to suppl.y 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 perntit or <br /> Zicense. <br /> a, If your requested permit or 3icense requires Councii ac��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 full. name is required to proc�ss this application or <br /> permit. <br /> ��C � ���r- i.vl '�.� <br /> J �:� � r� �� <br /> First iddle Last <br /> � 7 � > > l���c� �'�✓'CC f�r'���'j <br /> Address <br /> (_ �� Y �., �� /Li c�- ��� U�l� <br /> City State Zip <br /> �/�) / ._ � l �/ V <br /> � � > / <br /> Phone <br /> I understand my rights as stated above. <br /> .i <br /> �� �__. <br /> // ��� <br /> �c>�� 4 <i c.r u�=` . <br /> Signature • <br /> BUILD(NG&ZONING—473-7357 • ADMINISTRATION&FINANCE—�73-7358 <br /> • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />