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r <br /> `:*-.1. <br /> uy ar <br /> CITY of ORONO <br /> ,. Post Office Box 66•Crystal Bay,Minnesota 5.5323•Municipal Offices <br /> ` { <br /> { On the North Shore of Lake Minnetonka <br /> O RO�VC�?' <br /> RATA, cam- .ARVX:J RX <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 /> 1,e14qa j,M <br /> First Middle Last <br /> ` sgJ24 6 fry ,(�r <br /> Address J <br /> tvaX4 1'4 -. �. . MN • . $S3. 9'l <br /> City State Zip <br /> 1/73-.2© 92 <br /> Phone <br /> I understand my rights as stated above. <br /> .- z. <br /> Signature <br /> BUILDING!ZONING—473-7357 • ADMINISTRATION.t FINANCE — 473 7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />