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'"-�. -- <br /> .t,...���,�.._� <br /> .r . �.�� <br /> ��.,��.� a.Y � <br /> .����`-" CITY of OlE�OI\T <br /> '.R ��� <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> Y: <br /> ,W - �_�. c� . <br /> On fhe North Shore of Lake Minnetonka <br /> DATA__PRIVACY ADVISORY <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 /> l. 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 reguested permit or license 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 /> �`��U�J� � o �.,�--1�� <br /> First Middle Last <br /> . -, <br /> . � 1 —� � , <br /> '��-' � `���-�/`.�, i Nt�tu_. __. �c/C y - - -- <br /> Address <br /> . ��� �, , .����� <br /> _ _ . <br /> _ _. _ <br /> ,U _ ���- - .- - - -- - - <br /> _ . _ ___ ___.___ __._._.... _ _. __.__ ______ <br /> City State Zip <br /> � � ��`�- . <br /> �F l -- --- - - - ----- <br /> Phone <br /> I understand my rights as stated above <br /> S ' ature <br /> BUILIIING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSI\G <br />