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F t � � <br /> c�',�';'� 4> M1="� <br /> �Z. �;�: � «'.�a .,. <br /> t, ��� �����.� NO <br /> �,���.�-��� �,. Yj CI'TY of ORO <br /> .'n h I-ti.�v(��.�` .'-:'�(f '� <br /> ��,�_,,r' ',�,�,,y�'� Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> ��i� <br /> s�} ',fr' �'�r��: <br /> �� . �''F"'"� 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 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 license 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 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 /> _. . . ------- -_ _ - -� _- ----- _ _ _ _ __- <br /> -- - ---. _. ___ . .-- -- <br /> First Middle Last <br /> - -- .. --- _ _ . .. . . <br /> Address <br /> _ . _ ---- -�- ----- -- ---- - _...__ -- -- --� -_- . .--- -� __. -- --- -�--- <br /> City State Zip <br /> _ _ _ ---- - -- _ _._ <br /> Phone <br /> I understand my rights as stated above. <br /> -- - --- -_ . -- - - - <br /> Signature <br /> BUILIlING&ZON[NG—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />