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,w � <br /> � <br /> CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minneaota 55323•Municipal Off'icea <br /> • <br /> o _ � • On the North Shore of Lake Minnetorcka <br /> D�1�� ���� ���9�Y � <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 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 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 /> �.$�r—'� � ��aa�------ --� <br /> ,_v6� ---�-T---`�-�------- --- - ---- � . ._.. ._. <br /> .__ . .._�_._.__ --- - <br /> First Middle Last <br /> / SC> >- /�A+�,K ci/��"�_.__. _.___. _-- .. _ _..----_ . .. ... ._.__ <br /> -----._. ._._...___.... . <br /> Address <br /> --�..��4.aTio .....____�'�r J_ ..._.._._._.__.M�.__.--- ------_-•sJ�I/.�------•-•---..._ <br /> City State Zip <br /> y�� r�6�7 <br /> -- __.--.. .._.. ._._.. ...._ <br /> Phone <br /> I understand my rights as stated above. <br /> �� <br /> - - ..._. --------- - <br /> ture <br /> BUILi3ING&ZONING-473-7357 • ADMINISTRATION&FINANCE-473-7358 • PUBLIC WORKS-473-�359 <br /> A3SESSING <br />