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� oNo <br /> C�TY of OR <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•MuniciPal Offices <br /> • <br /> � � � � On the North Shore of Lake Minnetonka <br /> D�TA PRIVACY ADVISORY <br /> Zn 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 Iicense 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 license requires Councii actior. <br /> to approve, some inf ormation 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 /> rmit. <br /> � �. S �� � <br /> rst Middle Last <br /> .��, C�� <br /> Addr s <br /> CX��/�d /�N �S��S <br /> City State Zip <br /> �y <br /> Phone � <br /> I und rsta d my r ghts as stated above. <br /> � � <br /> Signatu � <br /> BUILDING&ZON[NG—473-7357 • ADMINISTRATION&FINANCE—473-7358 <br /> • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />