Laserfiche WebLink
�� a -r <br /> i � <br /> � CITY of ORONU <br /> Post Office Box 66•Crystal Bay,Minneaota 55323•Municipal Offices <br /> ! <br /> o _ � � On the North Shore of Lake Minnetonka <br /> D�1�A �R�YACY ADV�' SQRY <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> would like 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 supply 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. f' <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 /> ,r,S(�" �E"'� /Y��rR -•---�G�M� CI-- <br /> . ...------•- -. .....___.----'-- - -- �---- '-- ._..._. ..-_-•----.._. <br /> . .. ...__.. .--'-"--- �---.._. <br /> First Middle Last <br /> aq�6 ,�,�.,-�,�� � �s��d . .. . .__-- <br /> -- ------.__ _._. _ . _ . ._ <br /> Address <br /> """'"/�-'-_��`�.."'�_.._._._-_./�_ �f^-�""--i___..._._...."'_��r���"""__.___"'_"__.._"'... <br /> City State Zip <br /> ��.�.!�."' `.7�2=S�aY.___..--�-�------._..___�_ <br /> Phone <br /> I understand my rights as stated above. <br /> '— � '��� --- - -- -- ---- -- <br /> Signature <br /> BUILDtNG&ZONING—473-7357 • ADMIIVISTRATION 8c FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />