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� <br /> '. <br /> � <br /> CI'TY o� ORONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> � _ � � On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> In accFordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we would like to in�orm you that your reques�, for a permit or <br /> license from the City of Orono or any o� its departments may require <br /> you to furnish certain private or confidential information. <br /> �ou are notified that: • " . ; <br /> 1. The informa�ion you furnish wil.l be used to determine your <br /> < rqualification for the permit or license requested. <br /> � 2. You may refuse to supply data, but refusal may require that <br /> the City den� tY�e-:.permit or license. <br /> 5 <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 /> Iicense. _ . <br /> 4. ,If your "requested permit or, become e ub q�2res Caouncii. act�or. <br /> • to approve, some i�formation �ay P <br /> . �, <br /> 5. You hav+e certain rights under M.S.i 13.04 to review priva�e <br /> data on yourself. � � . • <br /> 6•. Your full name is required to proc�ss this application or <br /> permit. <br /> . � � . . �, �5�9 <br /> � 1 / C� G�`'o✓4- <br /> "� ��y Last • <br /> First Middle <br /> ��7�" �,�. .��b � <br /> Addre s A <br /> � �r l��1 �1 s-�Z <br /> City State Zip <br /> c���— ����"` <br /> Phone <br /> I u e stand ghts as s ate above. <br /> , i ature • <br /> � . .� <br /> • ADMINISTRATION&FINANCE—�73-7358 � PUBLIC WORKS—473-7359 <br /> BUILDING&ZONING—473-7357 , <br /> ASSESSING <br />