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i - <br /> .. <br /> � <br /> �. <br /> ! CITY of ORONO <br /> � Post Office Box 66•Crystal Bay,Minneaota 55323•Municipal OPfioa <br /> • <br /> � . � o On the North Shore of Lake Min.netonka <br /> � D�l�L �R�YA�.�S5,9RY <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 /> f rom the City of Orono or any of its departments may require you to <br /> furnish certain private or confidentia� information. <br /> You are notified that: <br /> 1. 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 local , 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 /> ._��__.�,_.�.� _ _.-. --.----_..__�- --_._. ---- . ___. ._�-�._... ��.�-----_ __. .... <br /> First Middle Last <br /> __ ---�='��'=:�_ . _ s���..�_.��.v�_�-:-----.-�-v?=�-���. �- .----__. __.. ... .__.__ <br /> Address <br /> -- -- �'`�"-��-'(�(�-�--�--. .._._�.�_.___.__ -�---... __�_._._..__..._------------�--- <br /> City State Zip <br /> ��1 �— � ` r1 �. � -- - <br /> Phone <br /> I understand my rights as stated above. <br /> �t r.�.X_ ' �` �...._�� -- --- - <br /> Signature �� <br /> BU[LIIING&ZONING—473-7357 • ADMIIVISTRATION&F[NANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> A3SESSING <br />