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� .� • <br /> ����� a�;�_ ,. <br /> ��: ���:� (��"I'�' �� O�Ol'�T� <br /> .. _� � <br /> -�ry� �` <br /> Y� <br /> '�� � �_ Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> �:��- �1 <br /> e - � o 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 /> 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 license 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 Iicense requires Council ac��or. <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your ful.l name is required to process this application or <br /> per-mit. <br /> � <br /> , �,�, � ��,� � �, �C�.� ;� : �� c� _ <br /> First Middle Last <br /> �3 0 � �r�\\: �a C�.v-e , S� <br /> Address <br /> �1," �1 ri4 a�C�l � 's �(Yl N �j r��a� <br /> City State Zlp <br /> � �,�. — `� ( ��I <br /> Phone <br /> I understand my rights as stated above. <br /> � ` <br /> � <br /> Signature . <br /> BU[LDING&ZONING —473•7357 • ADMINISTRATION& FINANCE—473-73�8 • PUBLIC WORKS —473-7359 <br /> AS3ESSING <br />