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w <br /> _. -y, <br /> � <br /> � � <br /> :s�' � <br /> � CITY of U�i01�'O <br /> . Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> •. <br /> � _ � � � On the Narth Shore of Lake Minn.etonka <br /> DATA__�RIVACY 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 /> Ybu are notified that: <br /> l. The information you furnish will be used to determine your <br /> � qual.ification 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 /> �icense. <br /> 4. If your requested permit or I.icense 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 fu11 name, and date of birth are required to process <br /> this application or permit. <br /> �� � r �z ��.4 0� -__. �v.u�r��,e..--- - ------ <br /> First Middle Last <br /> • - � . ._ . ._ .._ <br /> . �8� ---. �DiY� ! .:�- <br /> _/P ��.-- -...__.._.- - - - ----- <br /> Address <br /> YY f���i'�� /1 � �rSr � � 1-----•---- - <br /> City State Z1p <br /> �7 � "./ r'1 �l � ---- - -- <br /> Phone <br /> I understand my rights as stated above. <br /> ..�..._ --�----.__ .--- -------�---- <br /> -- --..��--`��-.._. .... <br /> Si ature <br /> BUILI3ING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSIKG <br />