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r � <br /> P <br /> j�' ,4 'r'��..� <br /> � ���� a <br /> n-t�ts�at r� �C�a CITY of ORONO � <br /> ��.�.�� ��i�. �; <br /> �'_"�,-rs��'� <br /> ' � '�� Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Officea <br /> A„�}��'A. <br /> y�� .�6�>�,�:r°"xv.5k''��c. <br /> � � On the North Shore of Lake Minnetonka <br /> .�, o ��, �� , <br /> DATA_ PRIVACY AD_VISORY � <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 Iicense <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 inf ormation may become public. <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 /> c <br /> _"' "'" '_ <br /> .. ._._. . . .. .. . .. .___'_" <br /> First Middle Last <br /> c <br /> -� � _____ <br /> Ad ress <br /> �� ��� S�� �;�-_ .-�------ <br /> City State Zlp <br /> �' �l - °? ��� -- -- --- __ _._ <br /> Phone <br /> I understand my rights as stated above. <br /> c <br /> Signature <br /> BUILDdNG&ZONING—473•7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />