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*�,� 1 k a <br /> �F-'iY�.'^,��'F9"'� ' <br /> b��':"�h�`r�'�n4ti;t'�`-�'�6-_ <br /> �"����'���� �i��� �� ����� <br /> � �:, <br /> �� � - � �,r�. <br /> � �,,�,. Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> ,�c� v 0��*��,,�� <br /> a�� ` On the North Shore of Lake Minnetonka <br /> ,� � ' e �` <br /> ,. _: <br /> DATA_PRIVACY ADVISORY <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> wouZd 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 /> qual.ification 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 Councii 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 /> ;, " � <br /> � �v�z�'_�� r e�T� <br /> �� �� <br /> - ---�-� ---.--.,- .--- - <br /> __ _.- - - ------ <br /> -.---- ---. - <br /> First Middle Last � <br /> _ ,� <br /> � _ _ !_5. '-- `�_ <br /> �--? � � _ _ . <br /> , �_�_5---.. - �-- r. �-�= ..__-.-4-. ..�----�--�--...__.----_....___ - ---. _._. .. _- - <br /> Address <br /> , — �. <br /> -� - <br /> �� �1 z���I4., �,r.� �-� ---�-�-�--->_ �-----•------•-- <br /> City State Zlp <br /> -- `t_.�� �- 'I�-�=---�---�-- ---------------- <br /> Phone � <br /> I understand my rights as stated above. <br /> ��.��_ --- ------ <br /> Signature <br /> BUILWNG&ZONING—473-7357 • ADMQVISTRATION�&FiNANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />