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� <br /> �� �l <br /> � ' Y <br /> O _.- O ���� <br /> - C���'" o� O <br /> ,� : � f,�:- _ ,� �t��►o� <br /> Posc of�ce soX 66 <br /> �`�,� ,`.,��, l �.� G'� Cn�stal Bay,>linnesota 553'�-006G <br /> ,. r. � <br /> �9kEsHag'� <br /> ,�—_. <br /> DATA PRIVACY ��DV�.SORY <br /> In accordance «�ith �1.5. 13.0=�. Subd. �, "Ri�hts of suojects or data", we would like to <br /> inform ��ou that your request ror a p�cm.it or license irom the Cicy oi Orono or any oi its <br /> departments may require �-ou co i�arnisn cenain pri��a�e or contidential in:ormacion. <br /> You are notified that: <br /> 1. The infonnacion you ruriish �vill be used to determine ��our qualittcation for the <br /> permit or licensz requested. <br /> ?. You may refuse to suppl}� da�a, but refusal may require that the Ciry der.y the <br /> pernit ar licease. <br /> 3. The information may be snared with other local, state or federal aQencies to the <br /> exter.t n�cessar}� to pro��ss «l� Perm�t or license. <br /> 4, If ��our requested permic or license requires Council action to approve, some <br /> information mav bec�me aublic. <br /> �. You ha��� ce,�ain ri�hts und�: �•S• 13.0^ (see fo!lo���in, paQ=) to review private <br /> data on ��ourself. <br /> 6. Your full name is required to process this application or permit. <br /> rLEasE Px��r <br /> c-, <br /> ';��.ti, ,�� �,r'� �����i�i0�'�--� <br /> First ��1idd:e Last <br /> -��C� I �,� f� �c�,J��- <br /> �ddress <br /> �,�i�r�+ ���v�` ��rv' `�5 3� � 3 6 �"�-�� / <br /> Clry <br /> State Zip Phone <br /> I understand m}� riQhts as sta�ed above. <br /> �,y�� ,���_ <br /> ���'� <br /> Sianature <br /> 6 <br /> � TEL.EPHO?YE-�3'T�'7357• E�.X-�iT3-O510 <br />