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.� , <br /> . �. <br /> CITY of ORON4 <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal OfFicee <br /> Y <br /> � _ � � On the North Shore of Lake Minneton.ka <br /> D1�T��R�ITACY �pV�SQ�Y <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 information you furnish will be used to determine your <br /> � quaiification 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 /> G�,�y ���e����v. :M---._.---_ __.__.. <br /> . _ . .----.---- ---. .----------.---- <br /> ---.---.--- --- _ __ . <br /> First Middle Last <br /> z 6 q s ����y �o�'�. _._ _._ __. .. . ._ ___ <br /> Address <br /> �,,rc��.S7o �1 rJ 5,�33 � <br /> _ .____. ._-----_._ ._____.----�-- __--- -------..._ <br /> ._.,_. ....----- -_._------__ _._ __.._._.._._._----.. _ <br /> City State Zip <br /> S�7I� O c1''�3 , <br /> _.. .-.-- ..___._____. -- <br /> Phone <br /> I understand my right�s as stated above. <br /> Signature � <br /> BUILIi[NG&ZONING-473-7357 • ADMINISTRATION&FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />