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� � <br /> �.,; r � � <br /> f �.,'f�� <br /> � � ��1��r �� <br /> � � a.��,� x:.�� �ig�� O� � � � <br /> 1�A t H: 'i <br /> p tV'r� s+'J <br /> 5 -� 06�� i� t� i <br /> �;��°a��k'�,�''�'� :;_� Post Office �3Ox 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> ' � h������� � <br /> �fe <br /> -'`� T ��'� On the North Shore of Lake Minnetonka <br /> c� �;p�,�%� <br /> ��t �,.. �Y>" <br /> �>.: <br /> DATA__PRIVl�1CY__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 Iicense <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 /> l. The information you furnish will 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 /> 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 /> .�L�=���_� ��,�-i� -�.�'/�S� <br /> First Middle Last '` <br /> ��S �.�/.��C�� �l/�=� . . _ _ __._ _- --._ <br /> Address <br /> /�'JO�,� �n,� _ _- .�a4�� __.__ ._-----�- <br /> _. . ___. __. --.-- .- --- <br /> City State Zip <br /> L Q <br /> / /—�v __._..--__------_.__. .._ <br /> Phone <br /> I understand my rights as stated above. <br /> -_ . __ ._ <br /> Signat re � <br /> �/; <br /> BIJILDING&ZONING—473�357 • ADMINISTRA'Tl &FINANCE—473-7358 ° PUBLIC WORKS—473-7359 <br /> ASSESSING <br />