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(.��i> • �R ' ^�''��J1 <br /> }�1���1 Y s"�� '^ . � . <br /> k`Sy�k�'�3�,�� }�f� � <br /> s <br /> h-�i r�j�� yt�Y,na��t�::+ <br /> IF ;..�1�_.y�.a �ITY of ORONO <br /> t e � � X <br /> -e, �►.��1'$r�,uL:� k:i <br /> " �.s •.vyY .,�e�-i. <br /> ��'-�y��',�,�; i�"j Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> , .,,� <br /> ,�¢' ,.`'C<'�";".�,`t <br /> � , i~" ; <br /> �,,� _ �;:"���` On the North Shore of Lake Minnetonka <br /> ... <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 /> 1. The information you furnish wi13 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 license. <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 /> Iicense. <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 /> _. . _,._._._ ___. .---. ------ <br /> _ - - - -- -- . ._._. __ _ ._ _ . .-------- <br /> First Middle Last <br /> Address <br /> . _ <br /> - <br /> . . __ _-- ..- - ----__ _._ _ ----- -- _ -- - -- ---- .._. -- - <br /> City State Zip <br /> _ __ - -- -- --- <br /> Phone <br /> I understand my rights as stated above. <br /> Signature <br /> BUILDING&ZONING-473-7357 • ADMLNISTRATIOIV&FINANCE-473-7358 • PUBLIC WORKS -473-7359 <br /> ASSESSING <br />