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� � . CITY o� OR�NO dl Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices i • � • � On the North Shore of Lake Minnetonka DATA_PRNACY 1�DVI_SORY In accordance with M.S. 15.165, "Rights of subjects of data", we would like to inform you that your request for a permit or license from the City of Orono or any of its departments may require you to furnish certain private or confidential information. You are notified that: l. The information you furnish will be used to determine your qualification for the permit or Iicense requested. 2. You may refuse to supply data, but refusal may require that the City deny the permit or license. 3. The information may be shared with other local , state or federal agencies to the extent necessary to process the perrnit or Iicense. 4. If your requested permit or license reguires Council action to approve, some information may become public. 5. You have certain rights under M.S. 15.165 to review private data on yourself. 6. Your full name, and date of birth are required to process this application or permit. � � _ f�f�' ti �`�°` - ttic. c.��i*.z�.. t' — �---. .... _.._. .--�-•---�----------�--- - — _ _ , .__._.:-_- -- _-_..._ - -- --�---- - -- ------ ._- Last First Middle - � � - � ,, r , � -- - ---- - - - --- . ^ . , . , . , . . . ..___. __ . .. .. _ __. . .. .. . .- . �_�._, ..._. _ _ _. Address , __..... -� .- � __., ? ; a F, . ,.,� r 1 - - --- - - _. __ ..i _'__ '.�_ ?----_. .°--._.....-•--�---. ._._. ----- -- --------------. _... . .. .. .-----�•-- City �`J State Zip �,� . .- � �� /_ f F f �� r� -------- ` --- -------- Phone I understand my rights as stated above. - � %�u.'� - --- -- ----- ---"�- --------- ---------.. ._.---._.__._.___._.___--. ._____._. Signat e BUILDING&ZONING-473-7357 • ADMINISTRATION�t FINANCE-473-7358 � PUBLIC WORKS-473-7359 ASSESSING 5