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. ' r �.. <br /> � <br /> �.. ' `,�-_,<si <br /> i t 4�e <br /> �• Y4. I F.,r �. `��t�� <br /> 1' � `" " CI7C'Y of ORONO <br /> � Yr�, r �w } ,�J ' <br /> � �:.. T'���' ���• . . <br /> , <br /> $ �� {� ' Post Office Box 66•Cryatal Bay,Minneaota 55323•Municipal Offices <br /> %�-?��;���'� , <br /> .��.:.:,�. ,4�'' <br /> ,e•. : . <br /> .��Ya ' � � On the North Shore of Lake Minnetonka <br /> `.' <br /> t , <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 15. 165, "Rights of subjects of data" , <br /> we would like to inform you that your request for a permit or <br /> license from the City of Orono or any of its departments may <br /> require you to furnish certa�n private or confidential inform- <br /> ation. � � � <br /> You are notified that: �� <br /> 1 . The information you furnish will be used to determine <br /> your qualification for the permit or license requested. <br /> 2 . You may refuse to supply data, but refusal may require <br /> that the City deny the permit or license. <br /> 3 . The information may be shared with other local, state � . <br /> or• federal agencies to the extent necessary to pracess <br /> the permit or license. <br /> � <br /> 4 . If your requested permit or license reqires council <br /> action to approve, some information may become public. <br /> 5 . You have cer�ian rights under M.S . 15. 165 to review <br /> private data on yourse].f. • <br /> 6 . Your ful]. name, and date of birth are required to process <br /> this application or permit. <br /> � � A��� ���;�S ��`������-� . <br /> First M}ddle Last <br /> Z�l C�C_� S t-��J� �C�1 <br /> Address <br /> c� �-C�=�.. n�� <br /> Date of birth ( oes not apply to building/general permits) <br /> "�� �-`�'y�� c . <br /> P ho ne �� ��.>L 1� J C �.,�.c.� <br /> I u ri ts as stated above. � �� ��'��� �'� <br /> X <br /> gna ure <br /> BUILDING&ZO NG-4 3-7357 • ADMINlSTRATION dE FINANCE-473•7358 • PUBLiC WORKS-473-7359 <br /> ASSESSING <br />