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� <br /> „"."3 �''z;� <br /> _' <br /> .:s, -. .,;. . ;_.y„ <br /> ��. <br /> _ ; ��l riv-•L K .H �ITY of �ROloTO _ . <br /> . ,.�=C::.-•-.�.-.�-,r1 <br /> cv��.�.aXi.'+ <br /> � <br /> .i Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> •: <br /> � � � On the North Shore of Lake Minnetonka <br /> .� - �..►. c� <br /> DATA__PR_IVACY 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 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 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 Iocal , 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 inf ormation 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 /> __. <br /> _------ -- -- - <br /> - ---- _..._ - - <br /> First Middle Last <br /> ��� S � �o �i�� -- - - - <br /> Address <br /> -1,�'� : �f_-. - .-��� ..__ -- -- --. .�->f��/.:- ----- . ------.-----..-- <br /> City State ZiP <br /> �l / ( 0��� ----- -- - -- - <br /> Phone <br /> I understand my rights as stated above. <br /> � <br /> .�_. ��`.'_: ._. . - ---_. _---- -.. .. .---- .------ - _ -. �---- ---- ---- ---�---- , <br /> Signature <br /> BUILDING&ZONING—473-i 35 i • ADMINISTRA770N&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIti G <br />