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"�^`:�, <br /> �rTMi Nt <br /> ���&°������i��' <br /> ����T,� ��':���.�= �i��� �� '����� <br /> • � t r� <br /> 43"�"' -�y� w`-��'�''°�`" <br /> �f���, ��� ,x,'".,�-f :;; Post Office Box 66•Crystal Bay,Minnesota 5a323•Municipal Offices <br /> -+�n��.,�-.--_�; <br /> : �:;�� r -;� <br /> �� � Y��, ;;� On the North Shore of Lake Minnetonka <br /> � -���, ,� ,�. <br /> DATA__PR_IVAC�' 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 I.icense <br /> f rom 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 supply data, but refusal� may require that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with other IocaZ , state or <br /> federa� agencies to the extent necessary to process the permit or <br /> �icense. <br /> 4. If your reauested permit or Iicense reauires Counci� 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 fu13 name, and date of birth are required to process <br /> this application or permit. <br /> ---- -._ _ _ . <br /> - -- --- ---- ----- --- - <br /> First <br /> Middle Last <br /> Address <br /> - _-- ----- --_ __ -�---- - -- <br /> .. - <br /> - __ ---- -_ ------- --- - _ _. __ <br /> City State Zip <br /> Phone <br /> I understand my rights as stated above. <br /> Signature <br /> BUILDING&ZOfYING—473-7357 <br /> • ADMINISTRATION&FINANCE—�173-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br /> 5 <br />