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Y..v <br /> R <br /> ����� x���j, <br /> y���:ti � <br /> 'LA .l J��y M� ��i'_�ay.u�� <br /> .t�y'�Y�.I�.o'4 iy,F'��(Y �i1 <br /> ._����:��� s���:� CITY of ORON� <br /> :r� �..� �;���;� <br /> �' ���9 ,�s'��� Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> �;`�.,. '�.'?,w�.';;;'+�, <br /> }���:,�z '"t, ' <br /> � �,..�; <br /> ,e� _ � ' � On the North Shore of Lake Minnetonka <br /> DAT�_ 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 /> 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 /> 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 local , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <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 /> /� - ,� � h � i �7-� � !-� r= � S �' "�� -- - --- - <br /> � ��,��, o. _ , <br /> First Middle Last <br /> ,. 1 <br /> �-{.?�S � � �� y C:! �- cL _ <br /> � �-�-�-- --_.. _ , . . _. . .__: ..__..`. �.._- - - ---- -�----- --_�._ ..__. _ .----- - <br /> Address <br /> �� �� � (� � n I �'/��� 5 .> 3 � =/ <br /> ���1_�-n�4.----�� �. ._.__ -�--- -- -- -- . -- --..__. -.--_---__ - ----- .-�----..._ <br /> City State Zip <br /> �-(� =�� �� � � 5:'� <br /> _ _ - --- - _...__-- -- - <br /> Phone <br /> I understand my rights as stated above. <br /> - <br /> -- _1't� :r�--` .. --- __� �—�_� ----_.__.._._..._. ..-------_ __- --- ---� - <br /> Si na ure <br /> BUILBING&ZONING-473-7357 • ADMINISTRATION&FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />