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. _ <br /> _ CITYofORONO <br /> GIS Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> OF <br /> - ORC3Nff 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 you furnish will be used to determine your <br /> ggalification 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 shared <br /> necessarywith <br /> to processlocal , <br /> the permit or <br /> federal agencies to the extent <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 /> L J, S <br /> First Middle L st <br /> o i #ADI%* 4heIC Rolt. L <br /> Address <br /> -v7i„., - 53:37/ <br /> City State Zip <br /> /05--- 13 37 <br /> Phone <br /> i understand my rights as stated above. <br /> --4„,,,,;;L, <br /> A ÷.4,,,,r____ <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE 473.7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />