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.e�._ <br /> =;�y ti'�''�� <br /> ti..:r k.- � <br /> ���������� CITY of ORONO <br /> ��.,��s.���, <br /> ��'F�-�.�.�- -�-. Y� <br /> �v+-��1�¢��Y'�+�...: <br /> �r���'� Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> ��tai G � -�:; <br /> �'�-`: On the North Shore of Lake Minnetonka <br /> -Y <br /> "�. . c� � �� <br /> DATA__PRIVACY ADVZSORY <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 /> 1. The inf ormation you f urni sh wi I i 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 /> federa 1 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 inf ormation 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 ap�lication or permit. <br /> - ---- --- . -- _ _- <br /> __ --- <br /> ---- _ _. __ - <br /> First Middle Last <br /> Address <br /> - ---- --- --- ------ <br /> _ _. __ --- - --�--- - -- - ----- --___ __. __ __ - <br /> City State Zip <br /> - -._ _ . <br /> Phone <br /> I understand my rights as stated above. <br /> Signature <br /> BUILDING�ZONING—473-i 357 � ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSI\G <br />