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�/ � � y � . <br /> ��r;� � �)�- <br /> �. . � ... ���� <br /> r � d P j �'A �� ' .�r <br /> � .. cITY o� oRo�vo <br /> f � <br /> t- y,�r S ''� F SI <br /> F .,,,.� I T,.r�Xn :N <br /> ;+ „r` �''"� ' "-�' � ';� Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Qfficea <br /> � `,:�,� <br /> s _ � A� On the North Shore of Lake Minnetonka <br /> DATA PRNACY 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 f rom the City of Orono or any of its departments may require <br /> you to furnish certain private or confidentiaZ information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your <br /> qualification for the permit or Iicense requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or Iicense. <br /> 3. The iniormation may be shared with other iocal , state or <br /> federal agencies to the extent necessary to grocess the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 �o review privat� <br /> data on yourself. <br /> 6. Your full name is required to process this apFlicatian or <br /> permit. <br /> , �� ✓V� " S �i� �'i l� �(' L C< -S �� � 'z—/ �� <br /> First Middl Last <br /> �' �' f� .S �<< (\ ` � � c�i�' � /� �? � <br /> Address <br /> `"// �'l�l. t rt1 c.� /` l vl "��j J � � / _ <br /> City State Zlp <br /> ,'_� � �._ � s-- <br /> �� h � <br /> " / l� � �"� � � ..� <br /> Phone <br /> I understand my rights as stated above. <br /> �,,— <br /> / � �-�%_,� �1 - .�- <br /> Signature � i�� ;; <br /> � <br /> BUILDING&ZONING—473-7357 • ADMIIVISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />