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� <br /> _�... <br /> .,� <br /> �' �3 <br /> nlum ���s l itj.�u.�� , <br /> . M',T���r ��X � <br /> r 2 i.' <br /> ^� (iI'�`�' O� �R�N� <br /> �R��,�1��V��}M�� <br /> �rs° '� �.. " �� •' Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> � `��..., <br /> '� " �� On the North Shore of Lake Minnetonka <br /> ; .� � • <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 /> Iicense f rom 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 �ocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or I.icense requires Counci i a�tion <br /> to approve, some information may become public. <br /> 5. You have certain rights �nder M.S. 13.04 �o review pri�a�� <br /> data on yourself. <br /> 6. Y�ur full name is required to process this apt�lica�icn or <br /> permit. <br /> -i- � � N� ��-. .•� - <br /> �_, � � �c <br /> F ' rst Middle Last <br /> .� �:� ,� ,, , � <br /> Address <br /> � ' ��,�-� S3 �- <br /> , � , <br /> Cit S ate Zip <br /> `���} - � �-� _ <br /> Phone <br /> I understand my rights as stated above. <br /> � � �� <br /> S ' gnatu e <br /> BUILDING&ZONING—473-7357 • ADMCVISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />