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� <br /> r �, � 4 <br /> ,� �N9 r <br /> �'°�^d'�, 2.� C� t j".,�` . <br /> � '��ek� � � �i ;'.� <br /> ���.��� �� �ti�s�' <br /> �: -� . = �I'��' of O Ol\TO <br /> n�' ,�.. + -;rf i r �: <br /> Jc��t.+r,tsc��3�.�r,1- �+ . <br /> 4 �i:•.•�.�-`»t-"�i <br /> �����k �'e 'f''. Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> ��F���C� . <br /> � � � x }ry�. <br /> �`� �'- On the North Shore of Lake Minnetonka <br /> � - �; � � °. <br /> ��..� <br /> ` DATA__PRIVACY ADVISORY <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 Iicense <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 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 Iocal , 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 /> ` _ - <br /> ���i �� �' � � <br /> � _ <. <br /> 1��r`t��.r-' ____._�_ _. _- ---- --- - ----�=h _-._ _. _.- _ -- �----�----------- - <br /> First Middle Last . <br /> S'�( %S:__..� Y.�� �-'.�.L" ��_� ? ij.0 � ,''7 - - --- - - -- <br /> Address <br /> �'l���i�.�-j�� l''t/� _ � S �� �--- .. ----- __.-----�-- <br /> _._ __ _---.. .._.- ----._ --- - .._...._-- ----- . <br /> City State Zip <br /> � y� ��y, �- ---- - --- --- --- --- - . <br /> Phone <br /> I understand my rights s stated above. <br /> �j� 1 <br /> /'L ../ j <br /> � u�/l„� '"_".'_"_.._' <br /> Signature <br /> BUILD[NG&ZONING—473-7357 • ADMINISTRATIOIY�&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />