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i � <br /> l- ' <br /> �� xYr i�-,+�M � <br /> ,� O� F H.. <br /> �n `� ��'��' o� (�R�N� <br /> �:�..� �.��.�a� <br /> n�'� ���"�`'�F�v:: <br /> a� 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 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 /> 1. The information you furnish wi3.1 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 iocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Council. action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 �o review priva�e <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> . <br /> S'-��� C� �� �� S�( :.� �.. �� <br /> First Middle� Last . <br /> 3� f� � �5�.�-� ��� � <br /> Address <br /> �j.J �.� 2 �a- T� �vV� � r ��J t1� _ <br /> Cit� State Zip <br /> T �( — 7�7� <br /> Phone <br /> I understand my rights as stated above. <br /> , � F <br /> � � <br /> ---. � �- <br /> . - Y._ __ <br /> Signa re — <br /> BUILD[NG&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />