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r <br /> ' � � <br /> � <br /> O � . � ���� <br /> ���'�' �f (� <br /> r3 ��i.:- ,�., «unic�p�ot�ces <br /> t.� �i' _� (�y Post Of��e Box 66 <br /> `�,� ' 1�. _ ',`: �J"�' Crrstal Bay,�iinn�sota=�323-0066 <br /> ��kESH�4� <br /> � - = <br /> D�,T:� PRIVACY ADVLSORY <br /> In accordance «�ith `i.S. 1�.0-�, Subd. �. "Rivhts of suojec�s o� daca". �;�e �vould li�e to <br /> inforrn ��ou that �our reauest ior a p�rmit or lice <br /> nse rrom the Ciry or Orono or any oi its <br /> departments mav require vou co �sriisn cenain pri��a�e or contidential inrormation. <br /> You are notitied that: <br /> 1. The info��acion �•eu �urn.ish «'iL be used to determine ��our qualification for the <br /> permit or license requested. <br /> �. You ma�� refuse to suppl�� da�a, but refusal may require r.nat the City der.y the <br /> perrnit ar �icense. <br /> 3. The information may be shared �vith other local, state or tederal aaencies to t}:e <br /> e�tcr,t ne�essar}� to p:J��ss ��1� Pe�r�it or license. <br /> 1, If ��our requested permit or license requires Council action to approve. sor�e <br /> ini�ormation mav oecom� DllD11C. <br /> � You ha��� ce::ain ri�hts unde: �I.S. 13.0? (se� fo?lo�j�in� p�Q�) to revie�v priv2te <br /> data on �ourself. <br /> 6. Your n.ill name is reqLired to process this application or p�rmit. <br /> PLEASE PRL1�`I' <br /> .L.. <br /> First <br /> ��liddle Last <br /> v �� <br /> _� dress <br /> � �,F,, _ yy^ � � <br /> ��� ,��� ���� � r�� �/ <br /> C1N <br /> State Zip Phone <br /> I understand my riahts as sta�ed above. <br /> SiQnarure <br /> v TEL.EPHO?YE--173-?357• F.A?C--t73-O510 <br /> I i <br />