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. ��'',� <br /> �..., -��a�z� � �'�''�--� <br /> ��� <br /> � : � ���'�' of ����T(�► <br /> x, ,p r ,�.�"�'� °19 <br /> , < <br /> ,r. �aY.y � <br /> ���'� �` ���� � Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> ?z t i ,'4� <br /> } �'� M1 4 <br /> J� !� �i f .� . <br /> ��` �""'`�``���""� On th,e North Shore of Lake Minnetonka <br /> � + .� �+ :e <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 f rom 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 Iicense requested. <br /> 2. You may refuse +�o supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other Iocal , state or <br /> feCeral agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii actio*� <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 �o review prica�� <br /> data on yourself. <br /> E, Your full name is required to process this applica�ian or <br /> permit. <br /> l � �'�,��i1f'���:✓� ���� <br /> First Middle Last <br /> ��/l �5�� �',�%���i.c�� — <br /> Address <br /> �/_.�C� �- ./��l� -s ,����'� <br /> City State Zlp <br /> �'� �� �/��s <br /> Phone <br /> I understand my rights as stated above. <br /> i a ur ' <br /> BUILDING&ZONING—473-7357 • AD!�iL'vISTRATION&FINAtiCE —473-7358 � PUBLIC WORKS—473-7359 <br /> ASSESSIN G <br />