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� a c p <br /> - CI'TI'of �RON� <br /> Post O�ce Bog 66•Crystal Bay,Minnwota 55323•Mnnicipal O�c:es <br /> i <br /> � _ � A On the North Shore of Lake Minreetonka <br /> D1°�iA..�R�GY AD....�..�9�Y � <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 license requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or ].icense. <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 ].icense 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 /> /�/G�ra��..� �U11.��� ����'.�.� <br /> Fir'st" Middle Last <br /> �--.� �� .��e��� �� -- - - <br /> Address <br /> � �� ,122/� ���.3_�-------�----- - <br /> City State Zlp <br /> ���'���--.-- -- - --- <br /> Phone <br /> I understand my rights as stated above. <br /> � <br /> ignature <br /> BUIL[3ING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC tNORKS—473-7359 <br /> ASSESSING <br />