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� <br /> _ � <br /> � _.'� <br /> _ _�... -� �iONO <br /> �ITY of O <br /> Posi Office Box 66•Crystal Bay,Minnesota 55323•Municipal O�ces <br /> •: <br /> � � _ � A �� On the North Shore of Lake Minnetonka <br /> DATA_PRIVACY AD_V�SQRY <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 dep�rtments 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 Iocal, state or <br /> . f ederal agencies to the extent necessary to process the• permit or <br /> �icense. <br /> 4. If your requested permit or Iicense 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 /> � ' , <br /> --- --- -�----- �- - - . ._ <br /> First Middle Las �� <br /> �p �,' � � , �5-�`� _ _ - <br /> . <br /> Address <br /> . 1'�''�-- �-�-`3 � y-----..._ <br /> ._ ._._.___ __ _ ___ _ .__ ._ ._.__. __. __._. .._____._____ ____._....__ <br /> City State �iP <br /> ���--�� � � - --- <br /> Phone <br /> I understand my rights as stated above. <br /> ��" - -�-- - - <br /> r .__ ' -"--' <br /> Signature <br /> BUILfNNG&ZONING—473•7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSIti G <br />