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� � <br /> .�"'�� <br /> �'��,�. °���`t� � <br /> � , ; �,�r� '� �:� <br /> � ,� S � -r,.' <br /> ���;��` � .�.��:���� �I'�Y of �hi01\TO <br /> ���`,�a s���ft'�,/' $�'� Post Office Box 66�Crystal Bay,Minnesota 55323•Municipal Offices <br /> .tl 4u ; �."!1 <br /> ir� �Q� � .. <br /> w: ,f x��.� p��.,*,:r <br /> �;�, , On the North Shore of Lake Minn.etonka <br /> , e� d �,. �:" <br /> ,Y;,--� <br /> _ ��., <br /> DATA_ PRIVACY ADVI$ORY <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> wou2d 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 will be used to determine your <br /> qualification for the permit or license requested. <br /> 2. You may refuse to supp3y 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 /> federa3 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 rights under M.S. 15.165 to review private <br /> data on yourse].f . <br /> 6. Your full name, and date of birth are required to process <br /> this application or permit. <br /> � _ . ���s <br /> ti�� - -.--- __ ._ . <br /> _. ._.---. _ = _= .--- _ __. _ _ . . ---.---- -- - / <br /> First � Mid Last <br /> � - ---_ _ . .. ._ <br /> � .�:r -._ . _ <br /> Address <br /> 1 � <br /> � __. .. .__. _. _�._.3.-�.._ .-�----- - <br /> Ci - - - - - ._ _State - Zip <br /> ��7 �� � � �� _----- .._ _ ___.._ <br /> Phone <br /> I understand my rights as stated above. <br /> � <br /> -- -. _ .._ . .. <br /> Signature <br /> BUILDlNG&ZONING—473-7357 • ADMINISTRATION&F1NA[VCE—473-7358 • PCJBLIC WORKS—473-7359 <br /> A3SESS[NG <br />