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.a,���&,.,.,. <br /> ! w f:+jr{ <br /> � wi 1' <br /> �#,Y.:'• y ' . <br /> L'� dA , 1 <br /> .e {L-�.; Y t <br /> ``4�`r �� �a �` , �I'��' of �ROl`TO <br /> ,yL�d ''�''+;Ft �. <br /> `5�:�a l,+wf.''. iu, y�.:4' - <br /> sj,�',�tti� ..`�^MJ'S 3 �; <br /> �y��,,�,:���"K,�"; Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> �i�a'��3��k" �`�r,� <br /> �-r. <br /> �`'� _ � �+` On the North Shore of Lake Minneton a <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 /> l. The information you furnish will be used to determine your <br /> qualification for the permit or Iicense requested. <br /> 2. You may refuse to supp].y 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 /> v�f�lll�✓ �j�l/r� --��ir�.�.-� --- -- <br /> First Middle Last • <br /> ��9.� ���-� ��� ----- _ . .___- <br /> Address <br /> �- <br /> i`�yI:__.. . _-. ---�_.__--��-�_ �-�----- - <br /> .!,����-�/= - ��_ _ --- - --------State P <br /> City Zi <br /> . <br /> __ __�/..��_-�d_��-.-----._._ _- -�- <br /> Phone <br /> I understand my rights as stated above. <br /> ._..__.._.._ -_ ..__.----.._. <br /> --- ----- ---- <br /> ---�.���_ __ ----. ._-----.- - .---- - -� <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADML*11STRATION&.FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br /> � <br />