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�f�� <br /> � <br /> C ITY of O1�ON0 <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Officea <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 /> l. The information you furnish will be used to determine your <br /> qualification for the permit or license requested. <br /> 2. You may refuse ta supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The inf ormation may be shared with other local, 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 Councii 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 /> �� � � <br /> �''�a r� r���s , . <br /> First Middle ast <br /> �� ,��x ��1 � <br /> Addr ss <br /> ��T�v ���l_J� <br /> City State Zip <br /> ���✓���� <br /> Phone <br /> I understand my rights as stated above. <br /> �---� <br /> � ��s�j. <br /> Signature . <br /> BUILDING&ZONINC—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESS[iVG <br />