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a _ • <br /> � <br /> - c ITY o� oRONo <br /> Post Office Box 66•Crystal Bay,Minneaota 55323•Municipal Oftioes <br /> • <br /> � _ � � On the North Shore of Lake Minnetonka <br /> D�1�� _���� AD��OR� � <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 will 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 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 /> �QI�� )� � 1 � ��._.Q"l� - - -- <br /> First Middle Last <br /> - --�_�. ___... �..'�a.�_.� <br /> ..�f.._......L��--�_.__. _...__.----. .. ._. _ .--.._. . ...... ___.__ <br /> Address <br /> ! �-- �5�.3-- <br /> � - --- - �--�--�- �-___.__._.. ...__._._--.._._._ --------..._ <br /> ----_�.�--�-----� <br /> City State Zip <br /> `�? �l - a�-3 3 .� , --- - - -- - <br /> Phone <br /> I understand my rights as stated above. <br /> �� <br /> Si ure <br /> BUILBING&ZONING-473•7357 • ADMINISTRATION&FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />