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��,� , <br /> y <br /> ����s f� <br /> ��C� � � N; <br /> } A t.r <br /> s��x1fi i��4��� f��� ��� � o���o <br /> �, '�� � +� � � <br /> � �c -e_;�� < <br /> ,�f��` 6� � . <br /> � k�`.��' �� ��i:', <br /> �� F � <br /> � ����'y���� "':� Post Office Box 66�Crystal Bay,Mineesota 55323•Municipai Offices <br /> 'Y`,��,�� <br /> ,�... <br /> ' �"�� � On the North Shore of Lake Minnetonka <br /> � q � � . <br /> DA1T�1__�RIVACY._ADV I�ORY <br /> In accordance with M.S. 15.155, "Rights of subjects of data", we <br /> would like to inform you that your request for a permit or license <br /> f rom 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 supp3.y 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 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 fu17. name, and date of birth are required to process <br /> this application or permit. <br /> ���//U� �,Ll����/n /� �.G/��!�..----� <br /> First Middle Last <br /> . ��� � ���� /9���c � <br /> Address <br /> � � 33 / <br /> � x���s�o� 1�� �. - _ - - - <br /> _..__ . __._ __.-- - .. <br /> City { State Zlp <br /> �71- 9�{5``� � <br /> Phone <br /> I understand my rights as stated above. <br /> ` ^ � ��'�'�-�... - - - - - - <br /> (-�-�.�1��'- - --- - ... . . . _. . _ _ .. <br /> --. .._. .. .. ._. � � . . . ._ �_ <br /> , <br /> Sign e <br /> BUILDING&ZONING—473-7357 � ADMINISTRATiON�.FINANCE—473-?358 • PUBLIC WORKS—473-7359 <br /> A3SESSING <br />