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�c= ©f ORONO <br /> ~�^r-- - Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> On the North Shore of Lake Minnetonka •_ <br /> DATA PRIVACY ADVISORY <br /> 0a , Subd. 2, "Rights of subjects of <br /> data", <br /> In accordance with M.S. 13•of Orono or any outhat your request for a permit or <br /> we would like to inform Y of its departments may require <br /> yicense from the City rivate or confidential information. <br /> you to furnish certain p <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your <br /> cualification for the permit or license requested. <br /> 2. You may refuse to supply <br /> data, but refusal may require that <br /> the City deny the permit or license. <br /> be shared with other local , state or <br /> 3 , The information may process rocess the permit or <br /> federal agencies to the extent necessary <br /> license. <br /> 4. If your requested permit or license requires Council 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 /> G f "5 C-4141014 e-cp 06 66006 S alta- <br /> w . ..,�-.im <br /> /I. % ' ' Ci' [�L•1 � Aar <br /> Middle <br /> First // <br /> Address *-5.72-l�^ <br /> -- <br /> .L`1-/ �� / I Zip <br /> City State <br /> 3/ -3/ 5 3 <br /> Phone • <br /> I understand my rights as stated above. <br /> . irddli - <br /> Signature <br /> UILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 <br /> • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />