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r. � <br /> .. <br /> � � <br /> CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal O�cea <br /> • <br /> � _ � � On the North Shore of Lake Minnetonka <br /> D�A PRIVACY ADV��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 /> l. 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 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 /> ,P'1I/� 1l �o..�.��v�_.- -- �------ <br /> First Middle Last <br /> 6�� _.._--.__ . .. ... __.__ <br /> `� ..--.---- ..... <br /> . ._ __ _ . .--. _ _,_ ..-----.. ._ ---_.------�-----� <br /> Address <br /> t/I�,bu��-c /l� �k/ �3 6Z - --- - <br /> City State Z1p <br /> �'7� � � �/ � <br /> --- ._.__. ..__ ._.__-- -- <br /> Phone . <br /> I understand my rights as stated above. <br /> /,�� _ __._----. ----� ------�---- <br /> Signa ure <br /> BUILD[NG&ZONING-473-7357 • ADMINISTRATION&FINANCE-473-7358 . • PUBLIC WORKS-473-7359 <br /> A3SESSING <br />