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Post Office Box 66•Ci-ystal Bay, Minnesota 55323•Municipal Offices <br />On the North Shore of Lake Minnetonka <br />DATA PRIVACY ADVISORY <br />In accordance with M. S. 15 .16 5, "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 deoartments mav <br />require you to furnish certain private or confidential info~m- <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 />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 ex~ent necessary to process <br />the permit or lice~se. <br />4. If your requested permit or license requires Council <br />action to approve, some infor~ation may become public. <br />5. You have certian rights under M.S. 1s:16S 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 />~tA <br />37~ <br />Address <br />Date of birth (does not apply to building/general permits) <br />Phone <br />I un <br />BUILDING "'-"'-'-''" <br />ASSESSING <br />as stated above. <br />ADMINISTRATION & FINANCE -473-7358 • PUBLIC WORKS -473-7359