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i � <br /> � L <br /> :��4 <br /> � �.;� <br /> ww^ry 1 j <br /> + , I <br /> � 1 �A.� <br /> .�'� � ,. � -,1 <br /> � � � CITY of OROl�� <br /> x::� ��;.. ::� <br /> ::�� �.�.- . . <br /> .�.-�:. �y Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> .,` _ <br /> ,,��� J �,: <br /> �:��p � � 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 /> 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 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 Iicense requires Councii. action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�� <br /> data on yoursel.f. <br /> 6. Yaur full name is required to process this apFlicatian or <br /> pe it. <br /> �, ��� ��- <br /> 4� � <br /> ' � � ' ` <br /> `� �. , � -� <br /> Y..� . " , t �. � �"_' <br /> F rst ��liddle ,� Last <br /> i �����'`) �\.,� � �• n � � '1-��-- <br /> Ad,d�%:�s s �..---- � ` .. <br /> , <br /> � � ��/�, , , '� . �/�� � �,� � l, � : (.�� � <br /> � � <br /> City State Zip <br /> , ;_ ., � � <br /> �1 � ` ` ;(�)C '�, <br /> � � _ <br /> Phone <br /> I understand my r�igh s' as stated above. <br /> /� 'j -- <br /> , �� , j <br /> j ��_ ---- - <br /> _ = �.� i; <br /> ,Signa�ur \ � <br /> I1 � <br /> `__- , J <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />