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A����-`a.�� <br /> �}'��} �y���� ~� .. .. <br /> �FY�r'� <br /> Mfi��'::, �ITY of �ROl\T� <br /> f������ <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> •:h <br /> ' �i <br /> �� _ � 4. �� ' On the North Shore of Lake Minnetonka <br /> � DATA_ PRIVACY AD_V_I_SORY <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 /> 1. The information you furnish wili be used to determine your <br /> qualification for the permit or Iicense requested.. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with other Iocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> �icense. <br /> 4. If your requested permit or Iicense 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 required to process <br /> this application or permit. <br /> � <br /> � � � zs.�- -- - - <br /> ____ _ - --- .--- _ . <br /> First Middle Last <br /> � , <br /> �� ` -- -- - - - - - <br /> Adctress <br /> � � - - _ -�- 7 -- -- -- -- -- - <br /> , - . �� ... _. . ._. .. <br /> ----- .- --- - _.__ _ <br /> --� - -- . --- --- <br /> ity tate Zip <br /> � -�..� - � -7 r � ---- - - --- - <br /> Phone <br /> I understand my rights as stated above. <br /> � -- ---- --- -- ------ <br /> `�-_ ----�-- _ ._ _ <br /> Signature <br /> BUILDWG&ZONING—473-i 3�7 • ADMINISTRATION 8 FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSI\G <br />