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� . <br /> , <br /> ti� <br /> �f <br /> r> r <br /> �#� .. t .� .,�� <br /> +.c� ..j t . ' <br /> a.4 .:i +1 t� <br /> �i� ���ry �� � <br /> ��� . F,T� y� ��TY of 0���� <br /> a 4�' -� ,:� . <br /> 9 <br /> ��zi Post Office Box 66•Crystal Bay,Minneaota 55323•Municipal Offices <br /> �''3"�i.� `-; <br /> a:��� 's, f .� <br /> ;� -� + � = On the North Shore of Lake Minnetonka <br /> DATA PRI�7ACY 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 /> I.icense 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 inf ormation may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�� <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> >.i � <br /> �,) �� 1� ��`����.v`�� :'1 1f f-�,�,,; a�� <br /> First Middle Last <br /> �._"( �`� �f 1--�k-.�r'`��j f�\�'� "+v ���r�� .) <br /> Address <br /> �_� ,�W-J ��.,� � �-~� r� � "j ;�_?-,�� � <br /> City State Zip <br /> C <br /> '�•_l 'l E �`���. <br /> Phone <br /> I understand my rights as stated above. <br /> L l, _`��,� ti �1 � � �`• � �JLJ � CS�} _ <br /> Signature <br /> BUILDING&ZO:VING-473-7357 • AD'�tL�lISTRATION&FINANCE -473-7358 • PUBLIC WORKS -473-7359 <br /> ASSESSItiG <br />