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Lt }�" <br /> ��'��� �� <br /> 3 <br /> �b���������� � ����� <br /> ,�� _ ����' � <br /> � _�,��� -�.� <br /> ` ' c 21> , �,_,: Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Qffices <br /> � A "'' <br /> Y, � _ � ` �,., 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 /> wouZd like to inform you that your request for a permit or Iicense <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 per•nit or Iicense 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 /> Iicense. <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 /> � � - �� ;� <br /> ��f�,'al�' � i�� �__� - --- � - ��� Lastf '---- - ---- - - <br /> First Middle • <br /> - - - � � <br /> �: - <br /> � �c-% �`_'�.`._.. � -- - <br /> Address <br /> � �= - i//-( / `�:C _L.��.�� <br /> J�� . 'J_----<=�` ,` . .. . t_V . __ _._.. .---------.. .- •---•- ----•-----�•-- <br /> State Zip <br /> City , , <br /> ; _ . �-�r�-,�� , <br /> �r /.::� - , , <br /> _�:._.__.-----� -'-- --- -- --�-�----------- <br /> Phone � <br /> I understand my rights as stated above. <br /> , <br /> ��;� %-if,';;�� � 1�+'���_ <br /> _ . <br /> � _._---- ---�- ----- ___�__----� --, .-- ----- <br /> --�----- - ._..C_ �_. __=-------.. .- --- <br /> Signature <br /> BUILIl[NG�ZONING—473-7357 • ADMQVISTRA'I'ION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSFSSiNG <br />