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� �����-. '� <br /> _:�'`� � <br /> �*,.ry1 � �:r z.�� CITY o� OR��T� <br /> � <br /> ��"� a � . �j Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> ;�, 7 3 a ' �:�'i <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 /> 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 Iicense requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with other iocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> l.icense. <br /> 4. If your requested permit or Zicense requires Councii. action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review prica�e <br /> data on yourself. <br /> 6. Yaur full name is required to process this apFlicatian or <br /> permit. <br /> .� <br /> � �{�- ���, � _� �: i r=���__--- <br /> irst Middle Last <br /> � � 1 �(-�� �f lL'�e c� �/i.,c.�;�_.. <br /> ��-��' <br /> Address <br /> �� ���"�" <br /> (�r 1 C:= � /� �...> <br /> City State Zip <br /> ��( — �1C'l.c � <br /> Phone <br /> I understand my rights as state above. <br /> c. <br /> n <br /> � <br /> l�����C-��r ,� -� �� �����C <br /> Signature , <br /> � <br /> �� <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />