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� <br /> C ITY of �RONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal O�cea <br /> • <br /> e � • o On the North Shore of Lake Minnetonka <br /> D���._.��� ���9R� <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 /> 1. The information you furnish wi l i 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 I.ocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> Zicense. <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 /> � Q.�1 . ..._ __� . ._ _. ----�-� _. <br /> . f4.!1!_�.. ._.. <br /> First Middle Last <br /> `Z e�� 1 .r��,�z�� w o o � .�� <br /> Address <br /> �A O v w � � � ��_.�..�.�._.___..-- <br /> City State Z1p <br /> � �t 2 L �7 � -- - - --- <br /> Phone � <br /> I understand my rights as stated above. <br /> Signa e <br /> _ - _. _ . _- : . _ :� _ <br /> _ . _ <br /> BUILDWG A�ZONING—473•7357 • ADMINISTRATION dt FMANCE—473-7358 • ' ' PUBLIC WORKS-4.73-7359 - <br /> A3SESSING _ _ - <br />