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. , <br /> ;`�} r�.R A , <br /> '3�i'�'%ta�'� �, ,�''� <br /> ~iY���,t` �:, h1,,� <;, .,� <br /> �� +��`=�`���}�� CITY of ORON� <br /> �'F?.k�! 45 • �;j <br /> `2 �C�_ �t ��^;�'1 <br /> �"'���� '����'; Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Office <br /> r�`'�` g��i=:�{; <br /> �. <br /> �X<�j�'r�.c ��1`ty+af <br /> :9��- �� `e � On the 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 license 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 /> license. <br /> 4. If your requested 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 /> � ��ll'1Q ,�- �� � ��r� L - <br /> First Middle Last <br /> � � 3 � c � 1 � I . -- <br /> Address <br /> � 4'.�1�� C�c4 �� f� `'1. ��� u . <br /> City State Z1p <br /> � �5=�� � � - -------- --- _ _ .._ <br /> Phone <br /> I understand my rights as stated above. <br /> � <br /> c <br /> � <br /> l � `Y1'� __ ..------ - -- --- --- - <br /> Signatu e <br /> BUILDING&ZONING—473-7357 • ADMLNISTRATIOfV&c FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />