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� <br />� � � <br />� �� _� <br />� � � <br />�X ��,-��,��h��ti � <br /> , :� �, 's.�C'.:. <br /> ����, 4 �t � CITY of ORONO <br /> *f �.� � �,�, <br /> ^�b �. �, rr ' �� <br /> 5 ;, �„r�,`,j��.;.> <br /> ?p ,"s� '� Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> tl `� �' <br /> j On the North Shore of Lake Minnetonka <br /> 1. <br /> • � • o <br /> DA,T�__�RI�ACY ADV�S_O_RY �' <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 ,i� <br /> from the City of Orono or any of its departments may require you to ,Yy� <br /> furnish certain private or confidential information. �� <br /> j�.i <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 supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other locai , 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 />� <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 /> Sl��4N�" __ . _ _1'li��a�'L _ _ _ ._ ... .._ ._�3uRxS__ --- __�___ . � <br /> First Middle Last <br />` .�z8- --. ..ON_Tf,�/o_ _._. . ...sT_...5-�•___ _.__ ___._-- .. _ _ . _.. .. ..... _ ._ ._ <br /> Address <br /> ,_ __ _ �v�P� l'`�,�j ssyi y <br /> - -_. ---- _._..___ . _---- -� - <br /> City State Zlp <br /> 3.3 i - �S-s�g . <br /> Phone <br /> I understan� ra?y rights as stated above. <br /> ._.. . . . .. _ _.. ... �._ _. _ . ..._. <br /> __.__. .. ._- - .. __ __._. _._,. . <br /> --_.._ . ..__. _. ___.. _ <br /> Signature <br /> � BUILIIING&ZONING—473-7357 ADMlNISTRATiON�BINANCE—473-7358 � PUBLIC WORKS—473-7359 <br /> '� A3SESSING <br />