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CITY of 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 vou furnish will be used to determine <br />your qualificati~n for the permit or license requested. <br />2 . You may refuse to supply data, but refusal may require <br />that the City deny the pernit 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 vour recuested Permit or license requires Council <br />acticn to ~pprove,-some information 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 />victori a Nelson Arneson <br />First Middle Last <br />3115 Cedar Avenue South <br />Address <br />Minneapolis, MN 55407 <br />Date of birth (does not apply to building/general permits) <br />Phone <br />I understand my rights as stated above. <br />X tJ/4,~ ~-r--~~~ <br />Signature <br />BUILDING & ZONING -473-7357 <br />ASSESSING • ADMINISTRATION & FINANCE -473-7358 • PUBLIC WORKS -473.7359