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i <br /> „z � <br /> •�+� � �k S,��� <br /> 1�,'k\ <br /> 2 f� <br /> �'�Y+ A�U,,q'^ ffy7ti � <br /> ..��` �{tj.F.s`e. ,r��t���� <br /> �,��r�����._"` a.� �ITY of ORON� <br /> �'r'.� "X.� 4a S <br /> �� ,e. � /f,�-� �•, <br /> ,�r,� '(,A,�,,�,��.,� �,t Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offic� <br /> y� "ft:o.. y��'k'��..� <br /> aa..�t ?✓;,t�•'�$n� <br /> �o��� <br /> On the North Shore of Lake Minnetonka <br /> . . , <br /> DATA__PRIVACY ADVISORY <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> would like to inform you that your request for a permit or license <br /> from the City of Orono or any of its departments may require you to <br /> furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your <br /> qualification for the permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other local , state or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or license requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 15.165 to review private <br /> data on yourself. <br /> 6. Your full name, and date of birth are required to process <br /> this application or permit. <br /> �,�Gt, �'.�5�1�� bu'T" <br /> �1�-- 1/u 11r�� pn'►'� �N'Z�l-'�-=�.-- - Y-£1�oA'E'�'�"S <br /> First Middle Last <br /> ?�Ar7 ---�'lo"�'` . /�_N.`.-�'--�---.._..._ . _. _ ._---�---------- - _ _ _.___ . . ,- .- <br /> Address <br /> I'��VS_' .__-�----- .- --- _ _ _-�N .�_. _ -- - -- --___.55�"E'.. ----- --�------ <br /> City State Zip <br /> 72)-'t.ol$-- -- -____ - - ----�_ -_____._ <br /> Phone <br /> I understand my rights as stated above. <br /> Signature <br /> BUILDING&ZONING—473-7357 • MLNISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />