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06/13/2002 14:19 FAX 952 844 3359 -· --·~--·.. -. ---- <br />J11n-06-Z002 01 : 1 Opm Fnlll"CITY OF OR, <br />SPECIALTY RISI{ SERVICES <br />t9!ZZ494818 <br />la] 006 <br />T•403 P.005/0D6 F•223 <br />CITY of ORONO <br />Municipal Offices <br />Streat Addrestt MaUlna Addrns1 <br />P.O. Box 66 2750 Kelley Parkway <br />Orono, MN 55356 Crystal Bay, MN 55323·0066 <br />DATA f!BTYACY AlWJ$0RY <br />Iri. aecorda~1ce with M.S. 13.04, Subd. 2. "Rights of subjects of data", we would like to <br />ill:f'onn you th.at your :request for a permit or license from the City of Orono or an.y of its <br />departments may· require you to film.ish certain private or confidential information. <br />You are notified that: <br />1. The i g.formation you furnish will be used to determine your qualification for the <br />permit or license requested. <br />2. You 1r.ia.y refuse to supply data, but :refusal may requjre that the City deny lhe permit <br />or lic!lnse. · <br />3, The iilformation may be shared 'With other local, state or federal agenoies to the <br />exten": necessary to process the pennit or license. <br />4. If ycur requested pemrit or license requires Council action to approve, some <br />infan~1ation may become public. <br />5. You bave certain rights under M.S. 13.04 (see following page) to review private data <br />on yrnJISelf. <br />6. Your full name is required to process this application or permit. <br />__ ~:-~<~~ \\\JY~ ~ocJ-\- <br />First Middle Last <br />L"Z-~S: ~'4,J\ ~ RL-k£ ----' Address <br />_\Nn~"'Z.4~ ~\j ~\ qs2-41.l6~ <br />City . lj State Zip Phone <br />---Sign.a.tu t'C <br />Telephone (612) 249-4600 • Ji~ (612-) 249-4616 9