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� � � <br /> � <br /> - CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> � _ � � 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 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 license 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 3oca1, s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Counci3. action <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 /> �V S.S t�� fl' /(/d ru v� <br /> First Middle Last <br /> 3 Z to y /l/ S li v r t �r <br /> Address <br /> �Vv.Y--,, �. f a, M �/ �.�3 4 � <br /> City State Zip <br /> ���ti� � �r- os�� <br /> Phone <br /> I understand my rights as stated above. <br /> _��_ �o -r s—s3 <br /> Sign ture <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION 8c FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />