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CTF^'- <br />uaRawa- <br />CITY of OROJfO <br />Post Office Box 66-CrystaJ Bay, Minnesota 55323 • Municipal Offices <br />On the North Shore of Lake Minnetonka <br />DATZi_£HJV^iC:ZLAgVIS-QRr <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 confidentla'l 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 sh^*-od 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 beer, e public. <br />5. You have certain rights under ^ <br />data on yourself. <br />15.165 to review private <br />6. Your full name, and date of birth are required to process <br />this application or permit. <br />4^s /5.HrCV. l-rlf/,'7] <br />First <br />Peni- <br />Middle Last <br />Address <br />......._ ' l' y]r}___-5$33./..... <br />City /state Zip <br />'-iT^ <br />Phone <br />I understand my rights as stated above. <br />Signature <br />BUILDING 4 ZONING - 473-7357 <br />ASSESSING <br />ADMINISTRATION 4 FINANCE - 473-7338 PUBLIC WORKS - 473-7339