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R <br />. - t <br />t <br />C3TY of ORO NO <br />Post Office N)x fi6eCrysLel Flay, Minnemita !,.02:16Municipal flf' ^v <br />On the North Shore of Lak. Annetonka <br />CA'I„ PRIVACY ADVISORY <br />In accordance with M.S. 15.165, "Rights of Suki)ects of data", <br />we would like to inform you that your rcquc•st for a permit or <br />license from the City of Orono or any of its departments may <br />require you to furnish cerLain F:ivate 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. "ou may refuse to supply data, but refusal may require <br />that the City deny the permit or license. <br />3. The inforr..ation may be shared with other local, state <br />or federal agencies to the extent neccasiry to process <br />the permit or license. <br />•1. I: your requested permit license requires COL =1 <br />aciion to approve, some inzorr:ation 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 re<ju.red to process <br />this application or permit. <br />QL LUsi LC.-IL-L.-I ABA ni Z M Last <br />firs <br />Address <br />_Lati.-Cz LA r t- 1A N ---- <br />LIA- <br />�5 <br />Gate rth (does not aj,-piy to builiLng/ge^eral permits) <br />Phone <br />I unAers_tanJ r-,, r i3Oit_ as st. <br />XAIL <br />Tli.rl <br />lnAt.11r0 <br />NI III�I�t.i/tN►t\t, �'1'1t' • 1I)VI\ISF0ATKA&FI%%W1 47t1154 • tKWN V%f*IL♦ 4'1'1�O <br />