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!'t � 4 <br /> e <br /> • !`i ,L��C <br /> � :r �l„ <br /> '` 1 L '�S. ,�� � �.F ti <br /> �" 'ri� <br /> i `-r� �3 rk �i��� �� ���`- � <br /> C } '�'-*''`�'i� , � <br /> � �,r�i . <br /> � � y ",'� Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> }�+�",�� - <br /> � x'ti :Y��.-. <br /> ' o m o,Ai�, ,;� On the North Shore of Lake Minnetonka <br /> ���4'�",¢a..�. � <br /> ��- .C.+.,�?=�=:�' . <br /> DATA__PRIVACY 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 /> 1. The information you furnish wi11 be used to determine your <br /> qualification for the permit or Iicense requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or �icense. <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 righ�.s 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 /> .• , <br /> ` '. . .I�C,�- - -- __ -- - . _. ' -/-�`' _'__ _ __. ._. - _ . -_l1. - -- <br /> F' rst Middle Last <br /> ' ' � - --�--. _ . <br /> . . .c��-�!�� _. _ _ _ _-__ __- - -- <br /> Ad r ss <br /> � <br /> o t � � --__. ._._ -- --.-� -- - -------..._ <br /> _ __ _ -- - ------._ --- - . .... <br /> _ _ __ _ .- --- - <br /> City State Zip <br /> �-_ -------._._ . -- .._ � <br /> Phon <br /> I understand my ' ghts as stated above. <br /> ,;r <br /> i <br /> ..r , � <br /> f. <br /> ._ __._'_ l'_ _ _'" ..'.' ' <br /> Signature <br /> BUIL[31NG.Q ZONING—473-7357 • ADMINISTRATION 1&F[NANCE—473-7358 • PUBLIC WORKS—473•7359 <br /> A3SESSING <br />