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_. . � <br /> . <br /> � <br /> ` �+ <br /> ., � ���.�: �- -�. . �I7��' of �ROl\T� <br /> Posi Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> •: ,. <br /> � _ � � A . On the North Shore of Lake Minneton.ka <br /> DATA__PRNACY ADV_I_SORY <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 license <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 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 /> �icense. <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 /> � �+�(,./.----- ._..__. _� - ���^3� <br /> -- ---..__. .---- - -- . <br /> First Middle Last <br /> -7_ U . � -�--��-- _ _ -- � <br /> . . .- -- <br /> Address <br /> ��CG�-l�/!1l1. �/U �..3�,��.�3 � --�-- -------..._ <br /> City State ZiP <br /> �471- �r�s 2 --------- _ ------ <br /> Phone <br /> I un e stand my rights as tated above. <br /> Sign u e <br /> BUILIIING&ZONING—473•7357 • ADML*IISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSI\G <br />