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.yY <br /> c" <br /> Am. . <br /> ..,.._,,.,...... <br /> 66 Crys Bay,Minnesota 55323•Municipal Offices <br /> '_z.::....!.------7,-'--1,"Z";--::: CITY of ORONO <br /> � �.- <br /> .:,,,, . . <br /> � Post Office Box • <br /> S��-� Minnetonka <br /> ::::;-: -'13V",- ; On the North Shore of Lake <br /> DATA PRIVACY ' p=SORY <br /> "Rights of subjects of <br /> Subd. 2, permit or <br /> In accordance with M.S. 13-our that your request for a p wirr <br /> y <br /> data" , we would like to inform y of its departments may req <br /> of Orono or any information. <br /> license from the City private or confidential <br /> you to furnish certain <br /> You are notified that: <br /> The information you furnish will be used to determine your <br /> I. for the pe- = t or license requested. <br /> cualification wire that <br /> City deny <br /> refuse to supply data, but refusal may req <br /> 2. You may the permit or license. <br /> the <br /> be shared with other local , state or <br /> 3. The information may <br /> federal agencies to the extent necessary to process the permit or <br /> license. action <br /> license requires Council <br /> permit or <br /> 4. If your requested on may become public. <br /> to approve, some information <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6 . Your full name is required to process this application or <br /> permit. <br /> ai. ",, i _.. "`` -- <br /> "� Mid., e%- Last <br /> First <br /> 3; S 3 .A.ts-' _w.--e--- <br /> Address3 , V <br /> -Plc („c„,---e_9- `tea' <br /> City p <br /> State Zi <br /> 2 - / <br /> Phone • <br /> I understand my <br /> ri-hts as sta above <br /> y <br /> Signature <br /> • ADMINISTRATION&FINANCE-473-7358 <br /> • PUBLIC WORKS -473-7359 <br /> BUILDING&ZONING-473'7357 <br /> ASSESSING <br /> 1 <br />