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� ' 1 <br /> 4 � <br /> e � IY'��� c�F.�� .�'V . <br /> :9]��£ ,3, � �.��!P6 <br /> �Y���;t����t���, C ITY of ORONO <br /> .� � aE * 4': <br /> ����� ;i <br /> '.� -�� � 3 <br /> �� '� "''ry''` Post Office Box 66•Crystal Ba Minnesota 55323•Munici al Offices <br /> �;: �.F� _,*, Y� P <br /> ,-��``t,s�� sti��� <br /> ..��:.,����.�, :: <br /> i�. ..:��'*e,, 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 /> would like to inform you that your request for a permit or Iicense <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 /> Iicense. <br /> 4. If your requested permit or license 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 /> / � d�..f�'��'C_�. _- _ <br /> ��-c ��_r�l _ �--�- - -- �--- _._. ,�./ <br /> _ _._ - _- --- � <br /> First Middle Last <br /> �7� 7 l/ ��cz r�- /��! U -� <br /> Address <br /> � ���� y--- ------- - <br /> ,l��✓.�.J [� <br /> City State Zip <br /> �i/- 5'!2- � - --- -----__----- <br /> Phone � <br /> I understand my rights as stated above. <br /> l-� _ ___._--__ __- - ------ <br /> ignature <br /> BU[LD(NG&ZONING—473-7357 • ADMLTVISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />