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Item#17-CC Agenda-01/12/09 <br /> Licenses&Permits[Page 4 of 221 <br /> 70Vv° <br /> C) . a CITY OF ORONO <br /> * Municipal Offices <br /> r���'1•'' - [y Street Address Mailing Address: <br /> )�,�'/}I°,a G� 2750 Kelley Parkway P.O.Box 66 <br /> r�L Orono, MN 55356 Crystal Bay, MN 55323-0066 <br /> 1'kEsSp� <br /> DATA PRIVACY ADVISORY <br /> hi accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data",we would like to inform you that your <br /> request for a permit or license from the City of Orono or any of its departments may require you to furnish <br /> certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your qualification for the permit or license <br /> requested. <br /> 2. You may refuse to supply data,but refusal may require that the City deny the permit or license. <br /> 3. The information may be shared with other local, state or federal agencies to the extent necessary to <br /> process the permit or license. <br /> 4. If your requested permit or license requires Council action to approve,some information may become <br /> public. <br /> 5. You have certain rights under M.S. 13.04 to review private data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> NAME:1 CA i krA ._. L--`! <br /> first middle last <br /> ADDRESS: _." <br /> 1 <br /> � cL--IS' <br /> o cv Lv e.., <br /> house number street <br /> \f\f0A,A9 0.—) 1 --'\Ir ' <br /> 5536 LI <br /> city state zip <br /> DATE OF BIRTH: PHONE:C,�90,_ 1 I — --Ptil <br /> month/ day / year <br /> I understand my r ghts as state above. <br /> 2,,,____,<, <br /> 6 .7 N116 ) \, k__K.. 12,- 3-, a ' <br /> ..,-----y_/ signature ., date <br /> Telephone (952) 249-4600 • Fax(952) 249-4616 <br /> www.ci.orono.mn.us <br />