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M ' <br /> CITY of �RUNO <br /> Poat Office Box 66•Cryatal Bay,Minneaota 5b323•Municipal Offices <br /> e <br /> � _ � � On the North Shore of Leke Mi�csietonka <br /> D���.���CY AD_�_O,�tY <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> would like to inform you that your request for a permit or license <br /> from the City of Orono or any of its departments may require you to <br /> furnish certain private or confidential information. <br /> You are notified that: <br /> l. The information you furnish will be used to determine your <br /> qualification for the permit or Iicense requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other local , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or license requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 15.165 to review private <br /> data on yourself. <br /> 6. Your full name, and date of birth are required to process <br /> this application or permit. <br /> _ K��sT�- --�-�---------- -----_..�-=--_._ �--- ----_.. .---.__�i���s_----.------. <br /> First Middle Last <br /> -- �33� ---.._��26�'�.E f�,-v� <br /> - - -- - - --� --� ° - - - -- <br /> Address ^ <br /> M �+�w c v�Pc,���s �-t+� �f�o_._.-------�------- <br /> ------ �-�-�------��------- <br /> ___._.-------�--.. . .._.._.__----._.....__.-_-_ �.z� <br /> City State P <br /> 85� - 1�5� ��o -c��ss�� <br /> Phone . • <br /> I understand my rights as stated above. <br /> ��� ��'i � V <br /> "`�� � — -— - -- -- - - = . <br /> � <br /> Signature <br /> � BUILDU�iG�ZONING—473-7357 . - • ADMINISTRATION 6!FINANCE—473 7358 f_ • � PUBLIC WORKS—473 7359_,- _ <br /> ASSESSING - <br />