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� . - <br /> �. .. V <br /> � �:� <br /> . '�, .A ORONO <br /> CITY of <br /> Post Office Box 66•Crystal Bay,Minneaota 55323•Municipal Offices <br /> •. <br /> o � • • ' On the North Shore of Lake Minnetonka <br /> DA�� PRIVACY AD_��QR�C - <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 inf ormation you f urni sh wi I i be used to determine your <br /> � qualification for the permit or Iicense requested. <br /> 2. You may refuse to supp3.y data, but refusal may require that <br /> the City deny the permit or Iicense. <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 /> Iicense. <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 yourself. <br /> 6. Your full name, and date of birth are required to process <br /> this application or permit. <br /> ��.J�;�;,�� �'�,,;,� A�u��.--- ---- --- - <br /> First Middle Last <br /> 'Lc�j25_._C��--� �? ------ ..._ .. _. . ------�-----...._..--- .. _ _ ._--- - . ..- -- --- <br /> Address <br /> ,�_�,�,;;..r� I„t� �S��� - -- --- - <br /> City State Zip <br /> �-� 4 �4� �5 ----_-----.�:. <br /> Phone <br /> I understand my rights as stated above. <br /> ,���v � --�-�---__ .--- ----�---�---- <br /> Signature <br /> BUILDING&ZONING—473-735 i • ADMINISTRA770N&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSI\G <br />