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. . ; <br /> �� <br /> -� ��'.r�' �� ���IOT� <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> 0 <br /> s � s • 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 yvu 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 license. <br /> 3. The information may be snared with other loca 1 , 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 Counci3 ac�ion <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri��ate <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> ��� lz�na.� �h\�n� <br /> First Middle Last <br /> 3�t�c� ,�,�nc-� �ha�-�, <br /> Address <br /> rn���,� �n� 5�53(�4 <br /> City State Zip <br /> �?1 - 7y�� <br /> Phone <br /> I understand my rights as stated above. <br /> o.�.� <br /> Si nature <br /> BUILDINC&ZONI�G-473-7357 • AD�i1NISTRATION&FINANCE-473-73_3 • PUBLIC WORKS -473-7359 <br /> ASSESSING <br />