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^`�� <br /> � � `�� =�..�� <br /> ;���� �� <br /> .: . . . CITY of OIi��TO <br /> , :� <br /> �4 <br /> �>��� ` Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> �-x.:.. ;,� <br /> <,,� '-� <br /> 'k»- -> 4 a:- ^� <br /> � -, � `r� ° On the North Shore of Lake Minnetonka <br /> ���� <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2 , "Rights of subjects of <br /> data", we wou3d like to inform you that your request for a permit or <br /> Iicense 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 /> 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 information may be shared with other iocal, state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Zicense requires Councii action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�e <br /> data on yourself. <br /> 6. Yaur full name is required to process this application or <br /> permit. <br /> �_���I� K�-,� 1�.��-� <br /> First Middle Last <br /> (GG�c� I�O�r-� �{��:�. G�c� <br /> Address <br /> (� `� �� � 5 .� � �� <br /> � <br /> City State Zip <br /> � �(� —4S��G' 3 <br /> Phone <br /> I understand my rights as sta`ted abo e. <br /> � <br /> _ �,� <br /> Signature , <br /> r <br /> BUILDING&ZONING—473-7357 • ADMINISTRATIOIY&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING - <br />