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. � <br /> ; � <br /> t CITY`o� O���T� <br /> M Post Office Box 66•Crystal Bay.Minne+ota 5a323•Mnniripal O�cee <br /> • <br /> � - • �: On the North Shore of Lake Minnetonka <br /> D�.��,P���P��� <br /> In accordance with M.S. I5.165, "Rights of subjects of data", we <br /> woul.d like to inform you that your request for a permit or Zicense <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 i�i n for1theypermit or Ii ensebrequesteg.determine your <br /> quaZifica <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permi.t or license. <br /> 3. The information may be shared with other Iocal , state or. <br /> federal agencies to the extent necessary to process the permit or <br /> I.icense. <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 ful7. name, and date of birth are required to process <br /> this application or permit. <br /> - �---.. ._. �--- -- -�---- <br /> . -�- - �aaie-- -- � - <br /> First <br /> --- -- - - - Last <br /> Addres� <br /> . ._ ._ --._.... . .--- -Zi--- -- <br /> City State �P <br /> Phone � <br /> I understand my riqhts as stated above. <br /> Signature <br /> BUII.DiNG&ZONIIYG-473 7357 • ADMINISTRATION�FIIYANCE-473-7358 • PUBLIC WORKS-473 7359 <br /> ASSESSING <br /> 5 <br />