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� a T"� <br /> k y:l f���4'�a � '_.'. . <br /> }4 Y �. �� S 4..ti_4 <br /> � � fr�'�� �� �`�:� CITY of O�iONO <br /> f � � , <br /> - r,f'�a4 p r. �,. <br /> ��-y.1�`�i+A�(�+.y l. � . <br /> F�`*.�`S u`'.�'S"�,,,,,,''k✓ �"'{c,:_:. <br /> �� ��d� ` _�` Post Office Box 66�Crystal Bay,Minnesota 55323•Municipal Offices <br /> Lti <br /> ��°Y 's <br /> "�l,'^�+t�� `� 6.q'� <br /> �% ��A� S <br /> �` �` On the North Shore of Lake Minnetonka <br /> a ' 0�r �'�, <br /> � DATA_PRIVACY ADVISORY <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> wou2d 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 /> 1. The information you furnish will be used to determine your <br /> qualification for the permit or license 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 /> �icense. <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 ermit. <br /> � ,�' _ -- -- -� - - ��i-��-�..�-E - ---___ _� i,�-'--�'j� - <br /> First Middle Last <br /> )z� � '�� r �� ��'�-�� �_���/. - ----- _ . , __ <br /> Address <br /> . _ <br /> C� ��i;�.)C� `2� � __.--.__._`.��_::�_<�,�.----�--- <br /> . _ __ --_ ._.._ <br /> City State Zip <br /> ���5- z i � �---- - -- <br /> Phone <br /> I unders y right as stat d ab e. <br /> � <br /> - �� y�, � ,����-�/ l� <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION dt FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> A3SESSING <br />