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. <br /> I � <br /> r <br /> � <br /> C ITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minneaota 55323•Municipal OfScea <br /> • <br /> � � � � On the North Shore of Lake Minnetonka <br /> D��� �R�ACY ���QR� � <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 wi13 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 Iocal, state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <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 full name, and date of birth are required to process <br /> this application or permit. <br /> a�-�---- _.--�--- -------�-----. .._--�----- -- <br /> - . .__.�l 2.105. .c-.�1.1.----- ------ <br /> First Middle Last <br /> r �� <br /> ?�� Sa���� ----_ __.. ...___ ._ <br /> Address <br /> - ---��- <br /> _�.... ---- �---------._ ----- �--...._. -- -- <br /> _. ._._...-------�--...._.-------•--.....__._.._. .- <br /> City State Zip <br /> ��. 7� ! 7� 2-0 - ---- -- - --- <br /> Phone <br /> I understand my rights as stated above. <br /> , <br /> � <br /> Signature <br /> BUILWNG&ZONlNG-473•735 i � ADMINISTRATION&FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />