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: ' . <br /> + . , , <br /> I <br /> i � <br /> c�TYo� o�oNo <br /> ; Post Office Box 66•Cryatal Bay,Minnesota 55.323�Mnnicipal Officea <br /> � s <br /> o � • o On the North Shore of Lake Minnetonka <br /> ���� ���_cY_���� <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 ypu to <br /> furnish certain private or confidential information. <br /> �, You are notified that: <br /> 1 <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 local , state or <br /> federa 1 agencies to the. extent necessary to process the permit or <br /> -�license. <br /> 4. If your requested permit or license requires Council a�tion <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 /> tfi�s application or permit. <br /> ,. �� � � .. <br /> ,¢� / ��da ----------. .__..--. <br /> First i e L t <br /> _--.�1_.�r..._ .. .�� _...�+_l.o�.cX-....--- . .. _ .___...... .._...---.__...........__..__ <br /> Address <br /> ....(.t/'�_. ..__ _ . ._ _.._ ..---••-���._.....__.._---..._ __._....--�-�---•----•--------- <br /> City State Zip <br /> _. ....__. ._..._..._._.._..---- - <br /> Phone . <br /> I understand my rights as stated above. <br /> \ �'—" �._ <br /> � <br /> S gnature <br /> - - -__. - - - - _ ._ ._ . __ ._... ._ _ _ _ . _:-- � - - <br /> = BUILDING�ZONING-473-7357 �• ADMINISTRATION dt FAVANCE—473-7358 . .: ! � PUBLIC WORKS—4�3-7359 _ <br /> � A3SESSING - _ _ . _- .. . <br />