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� <br /> �+,+,:�` <br /> "S`�n��7 �c� J. <br /> �� i� <br /> :�'� `� C�"�I' �� O��leT� <br /> .� � <br /> .:�.v. _ <br /> � • Post Office Box 66•Crystal Bay, Minnesota 5�323•Municipal Offices <br /> 0 <br /> , s - s o 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 Iike 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 confidentia3 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 suppl.y data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be snared with other Iocal , s�ate or <br /> federal. agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Councii ac��or. <br /> to approve, some information may become publ.ic. <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 /> � <br /> �U�� � � �������� <br /> First Middle Last <br /> �.� �:� ,�`/C,,/�� �>✓!'�, ��% <br /> Address <br /> L�4�-'36t.�=-� /j'���/-- ,5�.� �_J___- <br /> City State Zip <br /> y- ,� �- � �s'� - <br /> Phone <br /> I understand my rights as stated above. <br /> � � <br /> i <br /> a-�� � <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />