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� <br /> , CITY of ORONO <br /> � <br /> iPost Office Box 66�Crystal Bay,Minnesota 55323•Municipal O�ice+ <br /> i � <br /> � � _ � o On the North Shore of Lake Minnetonka <br /> ' D��� ���GY ���9R� <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 /> 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 /> 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 /> K 1 c 1��C'� 1� .���-����`�' --- - - -- - <br /> First Middle Last <br /> �� ��o r ��o t-2. ���" - - ------. _. ...... __ ___ <br /> Address <br /> /�.�z v.� � �_.t-.� -��--3��'�.�_.------�-- <br /> City, State Zlp <br /> � ��— ���� s — --- — -- <br /> Phone <br /> I understand my rights as stated above. <br /> -- _. ..--------__ .---� •------�---- <br /> ignaturey <br /> BUILDiNG 8c ZONING-473-7357 • ADMIIVISTRATION&FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> A3SESSING <br />