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� _ <br /> . f - �- <br /> _ . " y .. . _ � r. �. � ,� <br /> ---="r, _ . . - '� <br /> ;� 'n ' .:. <br /> ��'.��aJ- <br /> �"`� ,�,,a�-�°.' <br /> � � ��� <br /> �:.�V� .� ���� � �i��� O� ���N� <br /> �} ���-i� <br /> ��� <br /> . �`="=' . Minnesota 55323•Municipal Offices <br /> �� - _ Post Office Box 66 Crystal Bay, <br /> ! <br /> � _ � � On the North Shore of Lake Minnetonka <br /> DATA PRNACY 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 /> 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 will be used to determine your <br /> qualification for the permit ar Iicense 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 information may be shared with other local , e�i� or <br /> federal agencies to the extent necessary �o process the p <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Council ac�ior. <br /> to approve, some infor.nation may become public. <br /> 5. You have certain rights under M.S. 13.04 to rev�ew private <br /> data on yourself. <br /> 6, Your full name is required to proc�ss this application or <br /> permit. <br /> / <br /> � ���� � ���Last <br /> First Middle <br /> _�� <br /> �� -� s ���� w ��� ��� � , �� <br /> Address <br /> �� �� �` �" � L, �_. <br /> City State Zip <br /> � �� �`i <br /> Pho e <br /> I understand my righ as stated above. <br /> � <br /> '��� � <br /> Sign ure � <br /> BUILDING&ZONING—473-7357 • ADMITYISTRATIO[V&FTIYANCE—473-7358 <br /> • PUE3LIC WORKS —473-7359 <br /> ASSESSIN G <br />