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� � <br /> _ � <br /> C���' o� ��►�I0T0 <br /> r1!1 Post Office Box 68•Crystal Bay, Minnesota 5�.323•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 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 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 inforination may be shared with other Iocal , s�ate or <br /> f ederal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> a. Sf your reauested permit or Iicense requires Councii. ac��o% <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to rev�ew griva�e <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> p e,-mi t. ���}y2-�j/��'/"� l, �� �� / � <br /> , � � <br /> � �'^ �, <br /> �-%`�' �_7j��' ! ' _� `�-�`' l'i-J� � <br /> First Middle Last <br /> ,.� <br /> S!�� '7 �' C� �='�1./Dn����� i�� !_S � L-'I�-� <br /> Address <br /> ��� � c�c� 1� Y_' ' �'.� �� �-1 <br /> City State Zip <br /> L-� "7� � S"�' �J <br /> Phone <br /> I understand m ' ghts as stated above. <br /> � . <br /> Signature • <br /> BUILDING&ZONING-473-7357 • ADMINISTRAT'ION&FiNANCE-473-7358 <br /> • PUBLIC WORKS -473-7359 <br /> ASSESSING <br />