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, <br /> �: ,�'��=�:�A <br /> . � �F'E�����; <br /> " ' � �ITY of ORONO <br /> A�'Y �� ,'�R`4 w <br /> �.,.�nv.:,� »t�.. yf,�.. <br /> Rr�;�� ���.,�� <br /> Fp ?.x <br /> 'Q Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> � �Y .; <br /> .J4' �'.sc_ X.:` <br /> �,6��}Qbu�`ti F ��s.�.� <br /> �� - � t A ^� On the North Shore of Lake Minnetonka <br /> DATA__PRIVACY AD_VISORY ' <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> would Iike 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 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 Iocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If you?' requested permit or license 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 application or permit. <br /> ��T�. o�= ,���r�f ��zz�y y <br /> �C U�C��. _ _._ �d-1��.Q�1.--- __ _ �_ca`�°-.'2�_C�J_ _ ..--------__ __. ._.. <br /> _ _ . __---- --- - <br /> First Middle Last <br /> � U�,l� �� �� lV a�z..7tf - - - <br /> Address <br /> Y������,,-rrt � � ��5��1 1 - -- -- - -- - <br /> . _ _ ---- - <br /> City State 1P <br /> � 7�i^� �u� - --- --- -- _ <br /> Phone <br /> I understand my rights as stated ove. <br /> f <br /> Q <br /> __. . _ ---- - <br /> Signature ' <br /> BUILI3ING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7355 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />