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. � � - <br /> ���. <br /> �*� ���;� <br /> �,�: �+� •.J�'��`" <br /> R����=" -� �ITY of O]E��N� <br /> � . <br /> ����w�r, <br /> -���::�.��:; �:�, <br /> >�� �;; 3r :, <br /> _. rarF*„s,�-� <br /> �����h� Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Officea <br /> ,ar..�4 i�.r:, <br /> ,��a �.� �=� _w On the North Shore of Lake Minnetonka <br /> DATA__PRIVACY ADVISORY <br /> In accordance with M.S. 15.165, "Rights of subJ ermit o r Iic'ense <br /> would Iike to inform you that your request for a p <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 /> qual.ification 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 /> iicense. <br /> 4. If your requested permit or Iicense requires Council action <br /> to approve, some ir.formation may become public. <br /> 5. You have certain rights under M.S. 15.165 to review private <br /> data on yourself. <br /> 6, yp�1r full name, and date of birth are required to process <br /> this application or permit. <br /> /�t�' �C.. ��t-R�� �►���,�--� �r �c. <br /> First Midd� Last <br /> Z� v! ��I� �� - - - <br /> Address <br /> - __5 .._ . �i.--- --�--_ _ ----- ------- <br /> .-�--- _ — --- - - - <br /> -= - -- - -- <br /> Ci y State Zip <br /> ��1 - 1'���j -- ----- --- -- <br /> Phone <br /> I understand y ights as stated above. <br /> r <br /> S ' ature <br /> BU[LD[NG&ZONING-473•735 i • ADMINISTRATIOIv R.FINANCE-473-7358 • PUBLIC WORKS -473•?359 <br /> ASSESSItiG <br />