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�� <br /> .� •�, <br /> -��� <br /> �� �. m <br /> � � �x� ���1� � <br /> - � i��� ��'�Y �� <br /> �.. : ��r <br /> E -���. <br /> a %�'1�_='�-�: Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> u� <br /> ! ,��'Y'' <br /> ��,_ <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 Iike 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 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 , s`ate or <br /> federa3 agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Council. 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 process this application or <br /> permit. <br /> �;���=�r�rl r'- t>��v F rli i��� <br /> First <br /> Middle Last <br /> ��r _r-r- ,;�, ..- ri - : i� <br /> Address <br /> c��� : �, C= -� i� r`�,; j��C� ='�� <br /> City State Zip <br /> J`�� - �' 3�<-'� <br /> Phone <br /> I understand my rights as stated above. <br /> �� 7 <br /> � %! �' / -' �� <br /> � <br /> i � a ure � � � <br /> BUILD[NG&ZONING—473-7357 <br /> • ADMINISTRATION&FINANCE—�373-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />