Laserfiche WebLink
�'-` , <br /> � �� � � ����� <br /> �.���������. �, ��'��' � <br /> � ��;.�$��.,� <br /> � ��, _�� �.�; <br /> � «:;����`;�` i <br /> �� �,y � Post Office Box 66•Crystal Bay, Minnesota 5�323•Municipal Qffices <br /> ��i�r�-u_� <br /> � "r <br /> ��~���,....;� <br /> �:"�-�� '�r, r,� On the North Shore of Lake Minnetonka <br /> '�� - �; ,.� <br /> DATA__PR_IVAC`�ADVISORY <br /> In accordance with M.S. 15.165 , "Rights of subjects of data" , we <br /> would Zike 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 /> qual.ification for the permit or license requested. <br /> 2. You may refuse to suppl.y data, but refusal. may require that <br /> the City deny the pernit or Iicense. <br /> 3. The information may be shared with other Ioca1 , state or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense 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 yoursel.f. <br /> 6. Your full name, and date of birth are required to process <br /> this application or permit. <br /> � ` <br /> ����eJ�ZT__ <br /> Q--��, - �------- ---- <br /> . __,_. _._ <br /> - - - -- --�---- ----- ---- --- - <br /> First <br /> Middle Last <br /> „ .� �—� <br /> . . <br /> - ---- _ . ._ ._ <br /> _., . _. . .---- - ----_ --- <br /> -- -- - - <br /> __.._ ..._. . <br /> Address — <br /> `7 � -- -- <br /> ���� �-� --- - - -��-��y� - __----`�-r-.�'- ----___ ______�- <br /> ��_--- <br /> City � State Zip <br /> � 2 <br /> �f_�7 l _ �--�--�---�'--- ------�---------- <br /> Phone <br /> I understand my rights as stated above. <br /> �� <br /> , ---�----- <br /> � -- ---- - <br /> - _..----- --�-`= -- _-----�-- - - <br /> ----_---------- --- <br /> Signature <br /> BUILDING&ZOKING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br /> 5 <br />