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r <br /> _ /� � . � . <br /> s ` � ���� �� ����� <br /> a1�t�.' Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> ,. ,,a; � <br /> �.� _��� ,r s On the North Shore of Lake Minnetonka <br /> DATA__PR_IVAC�' ADVISORY <br /> In accordance with M.S. 15.165 , "Rights of subjects of data", we <br /> would Iike 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 Iicense. <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 /> �icense. <br /> a. If your requested permit or Iicense rec7uires 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 fu13 name, and date of birth are required to process <br /> this application or permit. <br /> � . _ _...�� ��------- --- � - <br /> �'� u-'-�----- _ _ .._ ..-- ----w��!/1.� --- � --.- _ � � <br /> First Mi dle Last <br /> n <br /> � %L .�,, c <br /> - .. .. _ . - - <br /> -_ _ _ _ _UI �uJ_.._ `�_ �_ - ---- ---- ------ .. _ — ---- <br /> Address <br /> ����� <br /> Ni �J ��_�_�_�-------��-- <br /> City ; State Zip <br /> ��/- �L��� ------ ---- -- <br /> Phone <br /> I understand my rights as stated above. <br /> - �' �� / // � - - <br /> Signatur <br /> BL'ILDING&ZONING—473•7357 • ADMINISTR4TTON&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br /> 5 <br />