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CITYof ORONO <br />Post Office Box 66•Crystal Bay, Minnesota 55323*Municipal Offices <br />On the North Shore of Lake Minnetonka <br />DATA PRIVACY ADVISORY <br />In accordance with M.S. 15.165, "Rights of subjects of data", <br />we would like to inform you that your request for a permit or <br />license from the City of Orono or any of its departments may <br />require you to furnish certain private or confidential inform- <br />ation. <br />You are notified that: <br />1. The information you furnish will be used to determine <br />your qualification for the permit or license requested. <br />2. You may refuse to supply data, but refusal may require <br />Lhat the City deny the permit or license. <br />3. The information may be shared with other local, state <br />or federal agencies to the extent necessary to process <br />the permit or license. <br />4. If your requested permit or license requires Council <br />action to approve, some information may become public. <br />5. You have certian rights under M.S. 15.165 to review <br />private data on yourself. <br />6. Your uIl name and date of birth are required to process <br />this application or permit. <br />ia�tc� F! t Middle Last <br />a 191 a CG4de-" �c <br />A ress <br />- - - _/� A-. )�) n .s 5 3 sC, <br />,ate o in - (does not apply to building/general permits) <br />Phone <br />I understand my rights as stated above. <br />X <br />nature <br />ci1� G/L�t t`tt� <br />BUILDING• ZONING - 473.7357 " • ADMINISTRATION d FINANCE - 473•7358 <br />ASSESSING <br />• PUBLIC WORKS - 473.7359 <br />�I <br />