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� <br /> �sc-lr4-2d00 11 .18�m From-CITY OF ORON4 +9522494616 T-169 P.022/027 F-850 <br /> %` �`\ <br /> � � �'� <br /> �� �, <br /> �, , o ����, <br /> = -- ��� CI�Y o� �R411T0 <br /> r� +�f�w�' _� �, ,', Munic�pai ot�ces <br /> ,�s: :, - <br /> ,,,� ,�. ,,f:q'�:: � "ti�;, <br /> �.� " �1� ��>>�'•° G-�" SVeet Address: Mailln� Addrass: <br /> � %''�� P.4. Box 66 <br /> ��9,���p4F/�� 2750 Kelley Parkway <br /> �f Orono, M N 5 5 3 5 8 C ry s t a i �a y, M N 5 5 3 2 3-0 0 6 6 <br /> ' DAT� PRN�Y An'VISORY <br /> In accardance with M.S. 13.d4, Subd. 2, "�ights o£ subjects of data", we would like to <br /> inform you that yoLtr request for a permit ar license from the City of Orano or any of its <br /> departments may require you ta furnish c�rtain private or confid�ntial infonnation, <br /> You are notified that; <br /> 1, The information you furnish wili be us�d to deterrz�inc your quatiftcatior� for th� <br /> perr,nit or iicense requested. <br /> 2. You may refuse to suppl� data, but refusal may require th.at the City deny the p�rn�it <br /> � or liCense. � <br /> 3. The in�ormation may be shared vvith othear locai, state ar �'ed�ral agencies to the <br /> ' extent neeessary to process the perm�t or license. <br /> 4 4, Yf your requested germit or license requires Council �Ciian to approve, some <br /> � information ma� hecome public. <br /> � <br /> ' S. You have Gertain rights under M.S. 13A� {see fallowing page) to r�view private data <br /> ' on yaursel� <br /> 6, Your full name is required to proc ss this applicatic>n or permit. <br /> �4---„�c�K �A�-ri� <br /> � ��-I'��/ 'M�—��� _ _. ��T�°,�✓ — — <br /> �First Middle Last <br /> � �I � CJ��"lC �l�l� ��i�� �/l�_ <br /> ! �dd.x'ess . ���, G�2 �. <br /> z ��,� � c �oa <br /> C1�� w� State Zip Phone <br /> � I understand my rights as state� above. <br /> � <br /> �✓�-r`-� � <br /> �1a11c1 � <br /> 1 i <br /> � Telephone(612)249-4600 • �'ax(61?)249-�616 9 <br /> � ; <br />