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_ �. <br /> ��'��' �� ����T� <br /> �d�t� Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> � -!3: <br /> .�� _�A� ,r' On the North Shore of Lake Minnetonka <br /> DATA__PRIVACY ADVISORY <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> wouZd 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 /> 1. The information you furnish will be used to determine your <br /> qualification for the pe?-mit or license requested. <br /> 2. You may refuse to supply data, but refusa� may require that <br /> the City deny the permit or Iicense. <br /> 3, mhe information may be shared with other Ioca1 , state or <br /> f ederal agencies to the extent necessary to process the per.nit or <br /> �icense. <br /> �. If your requested pe�mit or Iicense reauires Counci i action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 15.16� to review private <br /> data on yourself . <br /> 6, Your fuyl name, and date of birth are required to process <br /> this application or permit. <br /> ��c .. .. .----------- --- _ <br /> -�_._..._ .._ _ . _ <br /> - --- ---- ---- <br /> . __._: ._- �- <br /> First Ie Last <br /> �� ,� � � - - ---- _ - <br /> -- --- --- <br /> _.. <br /> Address <br /> _- ;� / / v � ��..1--'---'-'- <br /> � ._._-.-'----'.-"------'--� - <br /> .. _ . <br /> ./_!.t---_ <br /> y-- -_--------- --- - - - - <br /> Cit State Zip <br /> l� 7 � '- `� �� � 3 ---- --- ----- <br /> Phone <br /> I understand my rights as stated abo�. <br /> � <br /> �� ' 'l p ' � / ' --- ---- - <br /> -'��-----, <br /> '' -----��-�-- ---- -- - -._�. .. ---- `-_:- ----- --- <br /> Signature <br /> BUILDING&ZONING-473-7357 • ADMIIVISTRATION&FINANCE-473-7358 � PUBLIC WORKS -473-7359 <br /> .aSSESSING <br /> 5 <br />