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i. . . � <br /> ��'����y,':r t <br /> �l� y r:•a•. .`• �<,�s <br /> �. y�l�` ..,,,.: <br /> r��";r,c1 •- st-, �)ITY of OROloTO <br /> .,i � <br /> n"r�t,�� <br /> �fi.�.`''1Q ,..�,�'�y�:. <br /> ' �.,�,°-�° '' Posl Office Box 66•Crystal Bay, Minneaota 55323•Mnnicipal Offices <br /> ,w ,.. ,�, <br /> ;�'��'�.0 '�. � <br /> r,�+R�'. <br /> '"��: `` o ' On the North Shore of Lake Minnetonka <br /> ,�. <br /> �5; - <br /> UA�A__R��YA,C�ADY��A�X <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 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 /> 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 /> �� ��� --��la,��- - _�� 1��._ -_._ ��- � -'� !� <br /> First Middle Last <br /> /��'� t � - � /����� �/��-- - . - - <br /> Address <br /> ���I�"���'`� ' M,v ° ;� ��� <br /> , __ .. ... ._ _ ....._ . __ ._ _. ___ ._ <br /> City '� State Zip <br /> �j. �� � ��_" - - - - -- - <br /> Phone <br /> I understand my rights as stated above. <br /> � <br /> - _--__ .. ._. .__.._ _.. _ .--.- .. ..._ .__ <br /> Si ature <br /> BUILDING�ZONING-473-7357 • ADMWISTRATION�4 FINANCE-473-7358 • PUBI.IC WORKS -473•7359 <br /> A3SESSING <br />