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��� r yt. <br /> �!,4't��'Y4\�j Ii�ji1 <br /> � �• ��'y . ?;1� �:�. <br /> � K,�.,�� �1 , ��:: C I'1�Y o� O OlOT� <br /> t- �, r-: r' <br />. R ��'•'a r �y i <br /> � ,„}f ��,T Q�l���t��' ''x�' Post Office Box 66•Crystal Bay,Minnesota 553Z3•Municipal Offices <br /> r ti' � �f 4 , N <br /> ,� �k� Q�'�� , ".� <br /> � _ v 0 . On the North Shore of Lake Minnetonka <br /> � � D1�,��.A_PRIVACY ADVISORY <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 /> 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 germit 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 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 infarmation 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 Middle Last <br /> Address <br /> _ . __ _-. __..__....__ -- --- - ... ._.._. __ ._.. .. __. - __ . __. ..____ --.--------... . <br /> City State Zip <br /> Phone <br /> I understand my righfi:.a as stated above. <br /> -- _. --- _ ._.. . _W�_a <br /> Signature <br /> BUILUtNG&ZONING—473-7357 • tt[�At"JCS'ri2A1'ION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> A3SESSING <br />