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► ,� <br /> :�. <br /> ..`,'"� '�-� <br /> U f��S1�• '�7 <br /> .�r3'' `�eb��k�. �'� <br /> r_ - . _��:a� �ITY o� �RUI\TO <br /> .A Post Office Box 66•Ctystal Bay,Minnesota 55323•Municipal Offices <br /> _� _ `'-... <br /> � ' On fhe North Shore of Lake Minnetonka <br /> � ' �_e. A <br /> DATA__PRIVACY ADVI_SORY <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 Iocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> �icense. <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 /> �-.`I ��� �L\ ��``.1 �.,�'`G��L�F"l.� <br /> � 1.\Qv" -- -- <br /> ---- - _._._ . .- -- ----. . ---._._..._. <br /> . .__ — <br /> First Middle Last <br /> I �`7�. 1 , � <br /> � � ' �. _ . _ _ '?�-----. ..��. - -- <br /> � - _��, . � t-�:.�_ �5. - - - <br /> Address � <br /> . -��� r�'�,�� 5 5 .3( I <br /> (�C� • � �:� � ----- --------�- <br /> - - _ -- - .- ------- - -•- � _- - -- -- -- --� - -- <br /> _ --- ------- ------�----- <br /> City State ZiP <br /> lr � =�- �{ � 1 -7l _(J- <br /> Phone <br /> I understand my rights as stated above. <br /> �'���. _.. <br /> , ' --�-�---�� _�. .--- --- -- ----- <br /> Signature <br /> BU[LIIING&ZONING—473-i 35 i • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473•7359 <br /> ASSESSIIG <br />