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CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> i� � <br /> � - � � On the North Shore of Lake Minnetonka <br /> �ATA PRIVACY E1DVI�ORY <br /> In accordance with M.S . 15 . 165, "Rights of subjects of data" , <br /> w� wcaule3 :.ike to inform you th�t your reauest for a p�rmit or <br /> l.icense from the Caty af Orano c�r �ny of its d�par�ments may <br /> re��ir� yau to furnish certain private or confiderltial i�form- <br /> aiion. <br /> You .�re r.ati f aed that : <br /> 1 . The in£ormation you furnish wi11. be used �o determi7e <br /> your qualification �or �he perr�i� or license requested . <br /> 2 . Ycu may zefus� to sup�ly d�ta, but refusal m�y requir� <br /> �hat �he Ci..�.y c�eny th� permit �� license . <br /> 3 . The infarmation may b� shared with other local , state <br /> or federa? agencie� to the extent nece�sary fi:o process <br /> i:he permit or license . <br /> 4 . Yf your reguested permit or licen�e reqires cauncil <br /> action tv a�p,-oveo some 3nformation maj beconzc public. <br /> 5o Y�a have cert?an rights under M.S . 15 . 165 to revie�a <br /> p�-ivate data on yourself . � <br /> � . Your full. name , and date of birtti are required �o pracess <br /> this applica�ion or �ermit. <br /> Farst Middle Last <br /> Ac�,dress � � <br /> I3ate of birth (does not appa� to buildi�ig/genera� permits) <br /> F�hone <br /> I understanc3 my rights �s stated above . <br /> X � <br /> Sic�nature <br /> BUILDINU&ZONING-473-7357 • ADMIN[STRAT[ON&FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />