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- .� <br /> ���y:, �':',�: <br /> � J SS:,J <br /> �rk �� s � <br /> � <br /> �� v ci��Y O� ����� <br /> ����b <br /> .�;���.w.., <br /> �:F_^� � _ <br /> Post Office Box 66•Crystal Bay,Minneaota 55323•Municipal Offices <br /> � � � <br /> � • o � 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 3ike 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 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 reguire that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with other iocal , state or <br /> federa]. 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 to review priva�e <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> �. I A r�. �� � ��N <br /> '0 l.'v'/\ IZ� � <br /> First Middl.e Last � <br /> , `' <br /> � � � � ��� A �.IC� ie- � �� � <br /> Addre s <br /> }�}�� � ,� � � ,�� , � � � �� <br /> City State Zip <br /> �{� �' ` �� sl l7 <br /> Phone <br /> I understa my rights as stat d above. <br /> 1.�� C�'-�L.1L�i/> ...�—� <br /> Signature <br /> BUILDING&ZONING—473-7357 � ADM[NISTRATION�F[NANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />