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r <br /> ���* ��� <br /> �, s�R � <br /> �,�"```�w'e',�ar�'=`-:h'�„ <br /> t p , ♦� '� <br /> � � a� {1 ' 1 bn. <br /> ����, : at : �i��Y O� ����� <br /> � �, <br />_ Ip S.ecc.�" i�' 4. <br /> �y:e� <br /> ��,y` ;����,�°_�'�E �'" Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Officea <br /> "i�shP�""'�� ,'�;� <br /> � ��' '��' On the North Shore of Lake Minnetonka <br /> � " i c'�`:' <br /> .z� �` <br /> � DA��_PRIVACY _ADVISORY <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 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 permit or license requested. <br /> 2. You may refuse to supp].y 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 requirecl to process <br /> this application or permit. <br /> - - - -_. . ..__ _ .. ._-------- <br /> _ . .__...._. -- -- - -- __.._---- __ _.- - �- - <br /> First Middle Last <br /> Address <br /> . .. .._..---- - - -- ---- ... --- - _ . <br /> - _ _ .-- .. _-. -._. .._._. ,._.._.._ ._.---_..._ <br /> . <br /> ;, <br /> City State Zip <br /> __ ...._ .._. ._ ._. ._ <br /> Phone <br /> I understand my rights as stated above. <br /> Signature <br /> BUILDING&ZONI[VG—473-7357 • ADMINISTRATIOfY&FINANCE—473-7358 � P[.'BL1C WORKS—473•7359 <br /> A3SESSING <br />