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CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> • ' • • On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVTS�RY <br /> In accardanc� witta M.� . 15. 1o5r "Rights of subj�cts of data" , <br /> we would like to infarm you that your request for a permit or <br /> license from �he Ci.ty of f3rono or any of its departments cnay <br /> require you to furnish c�rtain private or conficlential inform- <br /> �tion . <br /> You are natified fhat : <br /> 1 . The infr�rmtatia,� y�u furnish will be used to determine <br /> yaur qualificat:�on far the germit or licPnse requested . <br /> 2 . You may ref�se to su�ply da�a, but refusal may requir� <br /> tY�.at the City der.y the permi� or 13cense . <br /> 3 . The inf�r��atio� may be shar�d w�.th other local , state <br /> or federal agerlcies to the er.tent necessary to proc�:ss <br /> the perr�i� or license. <br /> 4 . If your requ.ested permit or Iicense reqires council <br /> action t� approve, some in�nrmation may become publ.ic. <br /> 5 . You have cer.tian rights unc?er M.S . 15 . 165 ta review <br /> private data on yourself . ' <br /> 6 . Your full. name, and date of bir�.h are required to process <br /> this application or permit. <br /> / r;/ �' 1 � <br /> �= \'l C'� \��� rl t_ ��/� �-�����" _ <br /> First Middle Last <br /> ��"> >S- l����� �'�c= d�—�,� <br /> Address <br /> _ L���f�'�� �Ic��.� �~7.Ls� <br /> Uate of bir�h (daes not apply ta �u.ildi�ic�/general permits) <br /> �'�'7 �� - � C� }" �� <br /> Phone <br /> I understand my rights as state;d above. <br /> X� � ','"---� <br /> Sign � e <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSIN G <br />