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�' i <br /> � <br /> wY� � - .. <br /> � �ITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minneaota 55323•Municipal Officea . <br /> • <br /> � _ � � � On the North Shore of Lake Minrcetonka <br /> -- - - <br /> DAT�_ PRNACY �l_D_V��ORY <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 license. <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 Iicense 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 /> N I� N �-1 � l�� �c�2s d►J - - <br /> First Middle Last <br /> �? ca � S� Y��� �'� , .__._ - _ _ _---- ._.. .._-- <br /> Address <br /> n� �1�J� � � � �� '�i6 �- - -- ---= <br /> City State Zip <br /> �-� � - ���.� --�---..._._.----- <br /> Phone <br /> I understand my rights as stated above. <br /> ' , (/l"-� --.. .-------- <br /> Signature <br /> BUILD[NG&ZONING—473-7357 • ADMINISTRATlON&FINANCE—473-7358 • PUBLIC WORKS—473•7359 <br /> ASSESSIIG <br />