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" ` � <br /> •; � . <br /> ��r.R� �� <br /> � �; ��y��� <br /> 4 .. �a9 � f`d ���� �� ��0�� <br /> �v-� r . <br /> v"'- <br /> �'v`.!..n*,t�'?'?^J# i <br /> :.�t.�r,7`t�,_'' .i,4:Lr .,,... <br /> ,�O'�'`'"'����;f,;t�",,n33�`. <br /> °�.��.j�����^� post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> w�- lt Jf,, <br /> .�,�e✓r�& —' �d�y� <br /> r:t„s <br /> _�_ � ���.�`� On the North Shore of Lake Minneton a <br /> DATA_PRI_VACY 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 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 /> 1. 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 /> license. <br /> 4. If your requested permit or license requires Council action <br /> to approve, some ir.f ormation 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 /> � ,� --- -- ���_.__- -- /� � <br /> �� � <br /> First Middle Last <br /> 7�,�� - - . . .. . . <br /> � I"`-"-- - - ----- __ �_ <br /> - --. .. ___. <br /> Address / <br /> ��� �_ - -----���s�_ ----- .-.---- - <br /> City - --- - - - - - �State Z1P <br /> �� 4/_� ���� .__ . ' <br /> Phone <br /> I understand my rights as stated above. <br /> � - _-- --- - ---- <br /> Sig t <br /> BUILIIING&ZONING-473-7357 • ADMINISTRATION R FINANCE-473-7358 • PUBLIC WORKS-473•7359 <br /> ASSESSING <br />