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.�. -��, <br /> A <br /> �,�Y E�'"i Ti.�� <br /> " �x .s a o�� � <br /> �.,qr.���'�i "i <br /> � � Y <br /> � CITY of OR�NO <br /> � �:��&; �,,� <br /> _3.�}?�1'1n r�'�.•Yf <br /> h�-«_,�4 ':� 1 <br /> '�,,'F` ' ���'�'� Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Office <br /> �' .�,� '� v ,s�=.; <br /> �.�'�f';N�.,C t t,.,�.',��..;a <br /> .u�,,! � <br /> ;',,�"�' � y On the North Shore of Lake Minnetonka <br /> �,, - <br /> ,,�-r.,.;,. .... <br /> DATA__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 Iicense requested. <br /> 2. You may refuse to supply 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 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 /> ,p�� N K��;T�,� �I� L `._�— - - -- � s� ��c-- 3� <br /> First Middle Last <br /> ���� , �► G ���� �' �-- <br /> Address <br /> F-ni��!1.t' _"_ �'��.�c�-�-�—_._ '•__' ___.'"'___!�"�v_" ._.._ . .-'____'__._.��--�_J �".__ ._."_'_.." <br /> City State Zip <br /> _ . <br /> `173 _ /`� s--G- ---�- ----- ------ .._ <br /> Phone <br /> I understand my rights as stated above. <br /> r <br /> � <br /> tU..�L-�-� la �Y'��% <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADML*IISTRATIOfY&FINANCE—473-7358 • PUBL[C WORKS—473-7359 <br /> ASSESSING <br />