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4 <br /> _ � <br /> � <br /> �•rt:r� w <br /> A."'�'J� X--� <br /> i:ii'a ,�(�, � a"`."'p <br /> �}�':�F�,an��n � . .. �i��� �� ����� <br /> � � <br /> .,�:r"�`a7S.: <br /> .� <br /> Post Office Box 66•Crystal Bay, Minnesota 55323•Municipa]Offices <br /> _ _ ,_;� <br /> i: <br /> � _ � �_ ��� 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 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 /> �icense. <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 bi.S. I5.165 to review private <br /> data on yourself. <br /> 6, �our full name, and date of birth are required to process <br /> this application or permit. <br /> � • _ <br /> ---- ^`J� -(�t _'ri��'--�- --- -- - <br /> I C i,5`1_ __ - - -- - � ---._._.. . - <br /> First Middle Last <br /> a `� :•-c� /L� `-�/�� � ��r i V� - <br /> Address <br /> . `�r _� <br /> �//� �U � � � � .!C -1 -------�-----�-- <br /> �/�i-� -- - `�''-`�-.�'c <br /> City State Z1p <br /> L�7�- � /��� <br /> Phone <br /> I understand my rights as stated above. <br /> � <br /> � � <br /> � ���' <br /> � V � -- - ------ <br /> � - � � _. . _. .--- - <br /> �Signature <br /> BUILDING&ZONING-473-7357 • ADMINISTRATION&FINANCE-473-7358 • PUBLIC WORKS -473-7359 <br /> AS3ESSI\G <br />