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CITY of ORONO <br /> CITY Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> OF On the North Shore of Lake Minnetonka <br /> ORONO <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S . 15 . 165 , "Rights of subjects of data" , <br /> we would like to inform you that your request for a permit or <br /> license from the City of Orono or any of its departments may <br /> require you to furnish certain private or confidential inform- <br /> ation. <br /> You are notified that : <br /> 1 . The information you furnish will be used to determine <br /> your qualification for the permit or license requested . <br /> 2 . You may refuse to supply data, but refusal may require <br /> that the City deny the permit or license . <br /> 3 . The information may be shared with other local , state <br /> or federal agencies to the extent necessary to process <br /> the permit or license . <br /> 4 . If your requested permit or license reqires council <br /> action to approve, some information may become public. <br /> 5 . You have certian rights under M.S . 15 . 165 to review <br /> private data on yourself . <br /> 6 . Your full name, and date of birth are required to process <br /> this application or permit. <br /> DAVID C 2- 1E Gurt)oPJD <br /> First Middle /� Last <br /> 2-90C) LA) /}-7'F�7flW ..) i2 A-Q <br /> Address <br /> LI)tl - ,')l s-s 3a. <br /> Date of birth <br /> W.- 1lo - 3XS7 <br /> H -tog- 22'0(e, <br /> Phone <br /> I understand my rights as stated above . <br /> X ig �� <br /> nature <br /> BUILDING&ZONING-473-7357 • ADMINISTRATION&FINANCE-473-7358 • PUBLIC WORKS -473-7359 <br /> ASSESSING <br />