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_ �, � � <br /> ` � ����i' o� ����T� <br /> Post Office Box 66•Crystal Bay,Minaesota 5�323•Municipal O�ces <br /> M . <br /> • _ <br /> � - • s <br /> On the North Shore of Lake Minneto a <br /> DATA PRIVACY AD�SORY <br /> In accordance with M.S. 13.04 , Subd. 2, "Rights of subjects of <br /> our request for a permit or <br /> data", we Would like to inform you that y uire <br /> of Orono or any of its departments may req <br /> license from the CitY rivate or confidential in=ormation. <br /> you to furnish certain p <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your <br /> cualification for the pernit or license requested. <br /> 1 data, but refusal may require that <br /> 2. You may refuse to supp Y <br /> the City deny the permit or license. <br /> 3. The information may be snared withtQ P=oc sscthe pe=znit °r <br /> f ederal agencies to the extent necessary <br /> ?icense. <br /> a. If your req *' ermit or license recruires Councii ac�=or <br /> ues�ed p become public. <br /> to approve, some information may <br /> 5. You have certain rights under M.S. 13.Oa to review private <br /> data on yourself. <br /> 6, your ful.l name is required to procass this application or <br /> pe*-mit. <br /> �s� �4'CL� ��'�- �� I�VdC1��' <br /> First <br /> Middle Last <br /> ' i.�. ��,r.ct�' l� <br /> Addres s �5t�27 <br /> �,�'a�' U �`'iN z�p <br /> City <br /> State ` <br /> ��- 5�t Sc . <br /> Phone <br /> I und stand m rights as stated abo�e• <br /> v' • <br /> Sign ture � <br /> � • PUBLIC WORKS—473-7359 <br /> t3UILD[NG dc ZONING—473-7357 • ADMINiSTRATiON&FiNANCE—473-7358 <br /> ASSESSING <br />