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t~ <br /> _ '�Y�V ' <br /> ���� R�1�T0 <br /> CITY of O <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> - a, <br /> '� On the North Shore of Lake Minnetonka <br /> � o - � o <br /> � DATA_PRIVACY AD_VI_SORY <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> would Iike to inform you that your request for a permit or license <br /> f rom 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 license. <br /> 3. The information may be shared with other Iocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense 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 /> �� � n � <br /> � �,,�� _��s .- -�-- -----��--- --...-- --- _ _--- - - - -�- -.__ .---__ _.. ._. <br /> -�-- <br /> First Middle Last <br /> �� � �� ���-�� ��� ��27�� <br /> Add ess <br /> � , - <br /> �� � 2 <br /> ��i�'�l����, --- - ---�-��ti'�-.��_. ._ -- - --------�-�------- - ------�----��- <br /> City State Zip <br /> �� �� � S `�i . <br /> J - -- --- - - --_- <br /> Phone <br /> I understand my ri hts as stated above. <br /> �� ,� � � - <br /> li� � � •----_-.__ . <br /> L '_"""'_" .....'__"„".......""""'�'__".._.""""'...._'�__""_' '___ <br /> Signature <br /> BUILBING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLiC WORKS—473•7359 -'___ <br /> A3SESSING <br />