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a � <br /> �i��� O� ����� <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 PRIVAC7C ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we would Iike 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 to supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information 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 Council act�on <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 /> � �� � c� �r e�` c�.� <br /> p c.l,( � J �✓�- <br /> First Middl.e Last <br /> �� � � !� 5���� l�rz� �-� - <br /> Address <br /> `��/��.6� <br /> �� tu IC> ..► � S�� � � <br /> City State Z1p <br /> y� Z �- ���� <br /> Phone <br /> I un nd my rights s stated above. <br /> Signa ure � • <br /> BUILDING&ZONING-473-7357 • ADMINISTRATIO[Y&FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />