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i <br /> : �. <br /> C ITY of O�iONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Officae <br /> • <br /> � . � � On the North Shore of Lake Minnetonka <br /> ' D��,� �$�_�.���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 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 /> l. 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 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 Iicense 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 /> �i97e!'�E^�----. _.._...._.----__.-�-----�--�----� ---. . ___.�.�.''F�_�''4'eG='4"`-/f---_.._.. .... <br /> First Middle Last <br /> ,�y�t,erv}�i�-1° �� ��`r�S.e✓��-S <br /> �i�...�*�O . ..._ . .1��.7 ..�'��EGTi!�_._�'�vA_ <br /> Address <br /> --�s.�.�.._--------...- ----_ ..._.___.�''!=----__.. .._- ---.__.. ._^_._�._.�.��.-----.._._____..-- <br /> City State Zip <br /> ��z� ��� ��/� <br /> Phone <br /> I understand my rights as stated above. <br /> 'l..lG/P' �o'r�--`�`-�� - - - --- -- -- -- <br /> Signature <br /> BUILDWG&ZONING—473-7357 � ADMIN[STRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> A3SESSING <br />