Laserfiche WebLink
a '. � <br /> � <br /> CITY of ORONO <br /> Post Office Box 66•Crystel Bay,Minnesota 55323•Municipal OfSces <br /> • <br /> � � � � On the North Shore of Lake Minnetonka <br /> D�1�A �������QR� � <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 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 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 /> �---�_ .__ . . ---- �-------------�--�---� <br /> 4/.� -.-.-•- --- --- �-------�- ---.. . _ <br /> First Middle Last <br /> ��8� �1- srv� �� � . -- ---- <br /> Address <br /> ,_.��.__. .. _��_ _._-- �--�--._���--- --. ..._....------_s��� _.-------•-----�-- <br /> City State Zip <br /> �= 4�3 -,�77� --�---- - - - - <br /> Phone ,_ <br /> I understand my rights as stated above. <br /> � ._.._--�---- <br /> Signature <br /> BUILDING&ZONING—473-7357 � ADMINISTRATION 8c FINANCE—473-�358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />