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- � . <br /> �''�'+=. <br /> �.��l� <br /> ,y'� J,� N� <br /> a� k t w > n:n Wz��Wi <br /> ��Zr��'��;ry�����`y�� �� CITY o� ORONO <br /> M TT <br /> �c�s+f�`� <br /> 45.iry.J1J�A_� 4�fi�3� x'(i�� <br /> :..^4.5+�..'�'yP�*-.v..�"' . <br /> �� v <br /> ' "`'i Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> M:���,. <br /> ::v:,4-�+=� <br /> a;G:.:m�sf.c.�" <br /> ��`�o �� �A�"' On the North Shore of Lake Minnetonka <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 wi13 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 local , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <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 /> ��cv�P s ���<, lu S S ��� �s2_4,-�-- __. _. <br /> First Middle Last <br /> ��L S "� ��►� �s �-�, ` C� 1��� - -__ _. - _ <br /> Address <br /> '� �, �� � ��S 5 ��t f <br /> I�t...��.�-�,���.-��-� ---- ___.- - --�-- -- _ .- -- ------ <br /> -- - ------- ----- --�----. - <br /> City State Zip <br /> 7� � - �� � � l� - ---------- - --- <br /> Phone <br /> I understand my rights as stated above. <br /> . � <br /> �y�_ �_-.. . ��n'' . -��'�.�_ _ .- -- ---_ --- _._- --- - <br /> Si ture <br /> L <br /> BUILII[NG&ZONING—473-7357 • ADMIIVISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />