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Y <br /> ��� �s�. . ��;� <br /> �. �� b�f�r�' �� r . �� <br /> � C ITY of ORONO <br /> 'a"�,�,°��,��'� ,_ _�' <br /> �' �� �: �r r n <br /> � t ��1'q'S �� . <br /> 'F r,y� q �r,(' 1 <br /> ,!�a.'.� '� Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> � ��� � <br /> � - � ���� On the North Shore of Lake Minnetonka <br /> DATA_,PRIVACY__.ADVI SORY <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 will be used to determine your <br /> qualification for the permit or license reguested. <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 /> 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 /> J��11� 11-e ��c��- -- �r����S_�c� <br /> First Middle Last <br /> ���.�. ���.S�o _ _ C�.rc-�_..._--.. ._. .. . _ _ . � _ . _ _ <br /> Address <br /> `` �. __ _. _ - - �r� �_ _ ._ _._. .. _. _ ..3._�__l _. - -__ - <br /> City State Zip <br /> ,� a �8 <br /> . . <br /> `� � � - ^7 d � . . _.. ._ _ ___.___.. _ _- <br /> Phone C-��0 � 7 <br /> I understand my rights as stated above. <br /> _ _. _ . . .. . _ ��:�_-� -- -. ._. .. . _ ______________. ...__. . . . ___ _ <br /> Si e <br /> BUILDING&ZONIN —473-7357 ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />