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. .� •+ - <br /> � <br /> R <br /> .r 1� <.'�'� <br /> 7�,x � .-� V��ll . <br /> .y�'Li r. ! �`/I Y.._ <br /> ! <br /> . 4 '�a"'� t� ,,�y^��q <br /> r <br /> , � f�;������.�;� �i��Y O� ������ <br /> .��s,»�,,��.;�..�; <br /> -� �xr b�'i <br /> � r �'�,�--` '•«,'a�; <br /> �„rt ��.,`��.�'�,��}; Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offic� <br /> �°���.0 e` �"r"�'; <br /> �� � :� �*� On the North Shore of Lake Minnetonka <br /> . . <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 /> l. 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 /> 3.icense. <br /> 4. If your reguested permit or license requires Council actior? <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 /> _ �T ��� 2- --- -� � �� �=A'0 ___ _ ��.Y`��--�_ __ _ <br /> First Middle Last <br /> , � <br /> �-1 (a�, � _ _ I�o . ---- _S.._ .��-e- - - _._�_�.__1-� � _ _ --- - - - -- <br /> Address <br /> �;�u��; � , ov� �w '•�' S �� � y <br /> City State Zlp <br /> `��� �- S�_ �.�_._ _-- -- --- _ ___._ <br /> Phone <br /> I understand my rights as stated above. <br /> --- -- - _ - -___ . -- - �--- _-- - -__ .. ._---- — - - -- ----__ --- � -- --- - <br /> Signature <br /> BUILDlNG&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />