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� �� . . . Np r CITY of O�.iO • Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices •. � � � � e `� On the North Shore of Lake Minnetonka DATA_ �R�VACY ADVIS�RY 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: 1. The information you furnish will be used to determine your � qualification for the permit or license 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 Iocal , state or federal agencies to the extent necessary to process the permit or �icense. 4. If your requested permit or license requires Council action to approve, some inf ormation 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. .:- G� �n �_ 0_7.---�-�----- .--- - -- � 1 tG�f�c;(,.�__._-- -��-. _r�------- - -- -.- .._. ---�- First Middle Last ' .__. ._ .._ � �----•----._�_. -�- - _..---- - 73S �.�_7�-��_._ ..... . . . - - -- -�- Address Y � � � ��r�� _"_""""'_ -- - ._ro��V�-------...- ---._ ....._.._._. --•--•___. --•-._------ •- ------ City State Zip _.. �..2._.'_��.°--�—--- --�— --�---.._..---__ Phone I understand my rights as stated above. ,,,,.�(� 42 �,1��L�C,c•� __.___._ - ---.. ._-----.---- �- ---�--- .--- ____. .__.._. _...__ Signature BUtLD[NG&ZONING-473-7357 • ADMINISTRATION&FINANCE-473•7358 • PUBLIC WORKS-473-7359 ASSESSI\G