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r t:. <br /> /" \\E a <br /> � �• -�• r,q i�� �'y :�. . <br /> ���R t #� <br /> � 'i'�%Z � <br /> , � � �i�TY O� o��N� <br /> � ����,� <br /> r � .�. ��� � <br /> t a � �• <br /> � �'��'����'"' ` Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> F ��- , � <br /> � y�t����� � •".P <br /> i+:,. ��t_���s <br /> � �'° ''�`'� On the North Shore of Lake Minnetonka <br /> a�.�-'.���t-'� <br /> ����, ��,;, <br /> DATA__PRIVACY 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 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 /> l. The information you furnish will be used to determine your <br /> qualification for the permit or license reguested. <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 /> Iicens�. <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 fu11 name, and date of birth are required to process <br /> this application or permit. <br /> c� �u r� � J e.J C'ti✓L s��t_-- --S��( r ��r. <br /> ��-� --- -. _�..-- -- _ .._.._.__..._. �---. . --- - <br /> . <br /> First Mid le Last <br /> �� GI� � %�` � � � � � - - ._._ .._ -- .---_ . . ____ <br /> Address <br /> , <br /> - � � S� � �� <br /> � �� ���- -- -- � � __..._ <br /> _ _ ._. . �._ _ _ _.__ �- --- <br /> _.,.__. ._..._---..___. ----- ._.--- <br /> City State Zip <br /> _ � <br /> ��l" �(� �S� ._��7�_- <S-�/ wv�� <br /> � <br /> Phone <br /> I understand my rights as stated above. <br /> , <br /> �� �� <br /> , � � � . <br /> �' _4,Z z C c�._ _. . . . _. .__.______ _---- �--- ---- <br /> �1'-. --- <br /> . ._._ ._ . ......_ <br /> ignature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINAIVCE—473•7358 • PUBLIC WORKS—473-7359 <br /> A3SESSING <br />