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_ . • _ <br /> _.�,,� <br /> ��� <br /> ��j��.i ,�-� <br /> .4f��j�'¢M•�.�.4�A� <br /> a4. +,._.� �._., �'��Y O� ����� <br /> �•:�� <br /> ���,a�S; <br /> �__�=-�+�'yA�'�.1 <br /> , �� Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> .. - - .�,:r;�. <br /> P: <br /> ��_ � �, A� ' On the North Shore of Lake Minneton.ka <br /> DATA__PRIy_ACY ADV_I_SORY <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 /> 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 Iicense 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 local , state or <br /> federal agencies to the extent necessary to process the permit or <br /> �icense. <br /> 4. If your requested permit or license requires Council action <br /> tc approve, some ir_f ormation may become public. <br /> 5. You have certain rights under M.S. 15.165 to review private <br /> data on yourself. <br /> g. you•- full name, and date of birth are required to process <br /> this application or permit. <br /> �`� �� i� �J�'���'�- -- _.. <br /> First Middle Last <br /> � � l I � � r-�� �V _ <br /> � - -�--�_ _ _ �_ _ - - - <br /> Address <br /> � ti'l v�� �5 � v <br /> . � � � <br /> �'�-L-�S-- - --�----- -- - - - -- - -� -- - --- ----- --- _�=�--�-- - -�----�----..._ <br /> City State Zip <br /> � z �^ ° 7 � - --- -- --- <br /> Phone <br /> I understand my rights as stated above. <br /> , � <br /> / <br /> .�_���-- �-� ��-�-"- ��=- ----- -- _ ._ ___ _ --- - - - - <br /> Signature <br /> BUILDING&ZONING—473-i 357 • ADMINiSTRATlOti&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSI\G <br />