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•. .f •mm d::: .■ ■■?Sfed' .m::.mp^-■d .d :’v.^ >/’■•;■ .•■•,■ •••<»'•= ■.. •■ ^>:rf; • yj^tr! <br />I <br />S I <br />£ <br />M <br />»H <br /><0«laoucu <br />> <br />oo <br />•o <br />s <br />f-4 <br />c <br />•H <br />IM <br />0 <br />c <br />•H <br />i4 <br />1 <br />r ^ <br />O«s ^ <br />•4 <br />*o <br />*D< <br />2 <br />Oo <br />«H <br />£ <br />- o <br />O <br />c <br />«H <br />»4 <br />O* <br />o <br />•H <br />4J <br />Ift <br />U <br />« <br />> <br />o <br />o <br />*o <br />40 <br />X <br />MM <br />•O <br />€l <br />«ao <br />Vi <br />X <br />M <br />Cc <br />• • • <br /><M «H 4m <br />• • • <br />tt a tt <br />IM <br />a <br />o <br />C <br />a a c <br />f-4 a <br />M *H *J <br />a a o <br />•o aC 5n^ 9 a <br />V4 <br />a <br />us <br />o <br />%4 <br />V’ ■' <br />mymy-ry'jm <br />I? V‘'^ 4d <br />v^■'^. yV- y.,.:;y <br />■■-■■ ^' .Pyrn'* <br />• v!:-'V 'r •■ '-iM <br />imyp^pmppi,.«*¥ , •;: - i <br />my i:^:-:m yy <br />vv-.y . <br />?si^ <br />yy'Cf'dy <br />wm. <br />fm^yy ySyy^ <br />P^- <br />: - ' * V y ■;••■. . -\ ' :■.■■'■ ■: <br />yn:Pw-.> - ’ ■ ■ ■•*r :^ •• .y V\.'v!-:y.* y • 'y <br />y- yy/y-i-vV.. ■ ../ ■mm • yjv <br />'Mm^i <br />kpy^ <br />i f <br />•:. ;y ^^ -•••>' .. yy;•.■*< <br />lyy <br />8??' T*. <br />yi'-y.-yy > <br />-y;y?yi <br />jS0y»; <br />dsK?;;vvr,: <br />jk‘ <br />■ - *■ <br />0" • ■’'■mp <br />■ ::yPP:PiP:: ' <br />r ^■:", /: <br />i?. • 'P-mmyV-'VP y-yy - '. 'm-'-p- <br />■P ■p-y. pp- -y^P <br />•f;y-yy .-.v :■■ <br />i PSm^■ <br />3>..' J <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 />The information you furnish will be used co 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 reqirer council <br />action to approve, some information may become public. <br />Address <br />//pyyO'y r?y- <br />You have certien rights under M.S. 15.165 to review <br />private d ua on yourself. <br />Your full name, and date of birth are required to process <br />this application or permit. <br />Pf/LiPfU- A <br />First __ _ Middle <br />/ ( n /Jf/^ rnTy) / <br />Last <br /><S:s 9/ <br />bate of birth (does not apply to buildihg/general permits) <br />(J7/-rY39\ <br />Phone <br />I under^and^my rights aV7St^tcd above <br />Signature <br />-: V ppy^xypy <br />mt:;:^4:.Q y-:' ■ ■■'mmp.■ . m <br />Vy; pM <br />yrnyy. >■ <br />myp - f <br />^mmmymyyy. <br />!■:' ■ . 7 .Vy.’;- <br />. iiv,t ■• •• ■ • <br />^,r:--:y <br />'■ mx <br />r \ ■: <br />P. :•■ <br />:v vv s,y <br />wmvppppyy ypm <br />^pmmmpyy <br />* F 'yyy^.ykypp.: <br />A; j;---"-: ;; <br />u.m~ - ■ <br />mismkP <br />m. ■■■■:■ PK P. *m P 'P-P- • : <br />X^-p .:■ ir-yf:. <br />xymy:^:yy-\ <br />y <br />yXyyM-m <br />yy yyp^ <br />kppyy <br />fyyyy <br />r< :•!¥{md