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'; • . <br /> • � <br /> CI7l'Y Of O�iONO <br /> Post Office Box 66•Crystal BaY,Minnesota 55323•Municipal Offices <br /> � <br /> � _ � � On the North Shore of Lake Minnetonka <br /> DATA PRNACY ADVISORY <br /> ��In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data , we would Iike to infarm 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 /> 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 Xtenthneces aryhto processcthe p rmit or <br /> federal agencies to the e <br /> license. <br /> 4. If your requested permit or license requires Counci3. action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priy at� <br /> data on yourself. <br /> 6. Your full name is required to process this applicatioa or <br /> permit. <br /> s�'c�� �G; r�� ��'fJ��h <br /> First Middle Last <br /> �6'73 ����.��� �� <br /> Address <br /> ����/,i`pr /`'J/� 5�33/ <br /> City State Zip <br /> � �'/2 r���/-- 0 Z5s"' <br /> Phone <br /> I understand my rights as stated above. <br /> 1 ature � <br /> BUILDING&ZONING—473-7357 • ADMIIVISTRATION�FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />