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� � <br /> CITY of URONO <br /> Post Office Box 66•Cryatal Bay.Minneaota 55323•Municipal Uffices <br /> • <br /> � _ � � On the North Shore of Lake Minneton.ka <br /> DA����R�VAC�.�,�Y����� <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> would 2ike to inform you that your request for a permit or license <br /> from the City of Orono or any of its departments may require you to <br /> 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 suppZy data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other local , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or license requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 15.165 to review private <br /> data on yourself. <br /> 6. Your full name, and date of birth are required to process <br /> this application or permit. <br /> _.._.___._ _ _ �� -- - ---- __._�-.- ��z- <br /> _. _.�__.�_.._._. _ . .. <br /> First Middle Last <br /> �>��'s ������� ' - --- - - <br /> Address <br /> -- � - ----_. _.___ ...__������:�._.-•-----------j����--r--��------ --- <br /> City State Zlp <br /> ��3��.. --���.`_._7___._ - - <br /> Phone � � <br /> I und an y rights as stated ove. - <br /> --..- - --- <br /> Si re <br /> _ .. _ , � . _ _ _ <br /> _ _ - � PUBLIC WORKS—473-7359 ._ '--. <br /> BUILDING�ZONING—473-7357 • ADMINISTRATION dt FINANCE-473 7358 <br /> A3SESSING — <br />