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%;. <br /> 4 � <br /> �` Y`I� f>,� <br /> '�ZS ^�A d�y A� �;1 F 4!� <br /> .��� � �rA� <br /> ` � ���� � ���`._� CI'�CY of �ROloTO <br /> :� .��.�,��� � s �1 <br /> n K�:�♦ t.4�.':t��'i <br /> ��r:�it `'�� �:.�-��i <br /> "t <br /> �rii �� ��:�*�, Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Office� <br /> r�! � 7�� <br /> t ��C � � <br /> k 4v+4x+r� �+W�Y <br /> e���c�,�f� -� On the North Shore o f Lake Minnetonka <br /> ����� <br /> DATA__PRNACY ADVISORY <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 /> l. 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 /> Zicense. <br /> 4. If your requested permit or license requires Council action <br /> to approve, some information may become �ublic. <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 /> • . � �- <br /> _G_�___ - -- __.- -. -�1�,7./�-- - ---- - _.__ - �--- -�-�-�-. _. <br /> First Middle Last <br /> , <br /> oZ ��C� ���--�� ��D l� _. � <br /> <= � -- - , <br /> Address • <br /> ��"�C C' � C��Q�'� ��� -- - -- --- - -- - <br /> _ ^ <br /> � <br /> - � � � <br /> _ _ ----- _. _---- .- --- .. ._ .__ _- -- - -- .__ -- -._.__._- . ---- .. <br /> Cit�� , State Zip <br /> _ _� � �- _���- �� �o_(.� _ _._ <br /> Phone <br /> I understand my rights as stated above. <br /> ____._._ <br /> �' ��--,------_ <br /> '-----__' --. <br /> _._ _ _. <br /> � --- <br /> _ <br /> _. . -- -� <br /> --- - - - --- - --- . - -- -- _. ---- <br /> Signature � <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />