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CITY of oRoNC <br />r r: Rost OfG111�x`66.cn"lal Bay. Minnesota 553...3•Municipal Officer <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 rr 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 qualific-tion for the permit or license requested. <br />2. You may refuse to supply data, but refusal may require <br />that 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 full name, and date of birth are required to process <br />this application or permit. <br />/10R-X1" LC-ZtJIS vI6rKG uJ f-' A),gA'(Alo r c 1G�/�7�(rU�%�OLt vC'ic /1��72k12c1 <br />F1rZst NFU AM3i�J�,M N Last <br />Ad ess <br />3// 3/ �, l y/ Z,CIK <br />Date oobirth oes not apply to building/general permits) <br />q76- ;�(/9/ <br />Phone <br />I understand my rights as stated above. <br />X— <br />Sigriattire <br />MIILDING! ZONING - 47 3.7 35 7 • ADNIINISIk A nUN A FINANCE <br />AS : - i73 7758 <br />SESSING <br />114e,% &Zel loowlo(l� U 111416 U/ <br />0 PUBLIC WORKS - 473.73S9 <br />