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` �_. _ <br /> .�-� � NO <br /> . .^ �ITY of ��i0 <br /> Post Office Box 66•Crystal BaY,Minnesota 55323•Municipal Offices <br /> •. <br /> � _ � A `� On the North Shore of Lake Minnetonka <br /> DAT�i PR�VACY ADV_Z_SOR�L <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> would 3ike 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 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 Iicense. <br /> 3. The information may be shared with other Iocal, state or <br /> f ederal agencies to the extent necessary to process the permit or <br /> �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 full name, and date of birth are required to process <br /> this application or permit. <br /> r <br /> � <br /> ��e -. ._.--- - ------� <br /> . . <br /> o . _ _ _ Middle. Last <br /> First <br /> fS 7c�---� - 6'� . f_'�t.._ _ �'--------._. __. --- .. _ _---- _ _ . .- --- <br /> Address <br /> �o� �.�.�- �'r� - --����- -- -- -- - <br /> City State P <br /> �f�S�— 3 �4�S� - - - -- <br /> Phone <br /> I understand my rights as stated above. <br /> 1 re <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSI\G <br />