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10i18i94 16:26 TNE CITY OF OP,ONO 612-473-7357 003 <br /> CITY of OIi41eT0 <br /> Post UtliCe BoY B8•Ccyatel Bay,Minnesots 5.5323•Mutunn��� <br /> • <br /> • � � � On the North Shore af�ake Minnetonka <br /> DATA PRNI�CY A��SORY <br /> 04 , Subd. Z. "Riqhts of subjects of <br /> zn accordance with M.S. 13•ou that your requeSt f oz a permit or <br /> data". We wau18 Iike to inform y re uize <br /> license f rom the City of Orono ar any of its departments may q <br /> you tfl furnish ceztain private or conf�.dential information. <br /> You are notified that: <br /> 1. The information yQ� furnish will be uuested, determine your <br /> qualification for the permit or Iicense req <br /> Z. you may refuse to supply data, but refusal may require that <br /> the City deny the perm�t or Iicense. <br /> 3. The informatiion may be shared with other local , state or <br /> federai agencies to the exten� necessary to process the permit or <br /> license. <br /> 4. If yauz requestsd permit or 3.icense requires Councii action <br /> to approve, some inzormation may become p <br /> ublic. <br /> 5. You have certain rights under M.S. I3.04 to review private <br /> data on yourself. <br /> 6. Your full name is required to pxo��ss this application or <br /> pezmit. <br /> �I � ✓ <br /> > > � Last <br /> First Middle <br /> 1 " �� �� /� <br /> � <br /> Address � � �, /�`j ,' <br /> , ` y-��X <br /> Cit <br /> State Zip <br /> `�`-�j -/ � (� �, �?� <br /> Phone <br /> I understand my rights as stated above. <br /> C � <br /> Sig ature <br /> BUtLDING�ZONING—a73•7357 • ADMINIS7RA7ION�FI�ANC£—4�7-7358 <br /> • PU8L1C w'ORKS—473-7J59 <br /> ASSBSSiNG <br />