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����Y� � � �� � <br /> ,� �. : �i��� �� ����� <br /> ��{ � � <br /> '� �� �=;,,;k <br /> � �^x,,�� J`�'�''�'�r-� <br /> A <br /> .�,.:,„_: ����,,;,'�, Post Office Box 66•Crysta] Bay,Minnesota 5�323•Municip c� <br /> y" �)} wrY�1.CC� <br /> i;s �3�,,,��,.��1 �, <br /> �'.���,.:�:�.=••�s��'-��*� On the North Shore of Lake Minnetanka <br /> ,�:,. <br /> :t;i�W-';��� �� : <br /> DATA_PRNACY .ADVISORY <br /> In accordance with M.S. 15.165 , "Rights of subjects of data" , we <br /> woul.d �ike 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 confidentia3. 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 refusa3. 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 license requires Counci� 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 <br /> Middle Last <br /> Address <br /> -- -- -- ----- <br /> _ _ __ ----. .._... --�----- --- -_-____ - -- --- - - - <br /> City State Zip <br /> Phone <br /> I understand my rights as stated above. <br /> Signature <br /> � � ADMINISTRATION�&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> BUILDING&ZOIvING—473-7357 <br /> ,aSSESSING <br /> 5 <br />