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• 'i� � <br /> . f -Y <br /> � � . _ . _._ ._ .. <br /> CI�Y o� O��i1T0 <br />� Post Office Bo:66•Crystal Bay,MinneBota 55323•Municipal Offices <br /> i <br /> � . � � On the North Shore of Lake Minnetonka - <br /> . D�lT��1Z�v�i �IDV��Q.�3� • <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 confidentia�� 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 refusaZ 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 /> Iicense. <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 penait. <br /> �r���'S . _._.__L.�� _ . __. . _ .. . ._ ._ �N �1 __._. .._ <br /> �.. . _ ___ <br /> F'rst Middle Last <br /> 3� �-��1� . _... _.---.�. ..... ._.. __ � <br /> Address <br /> __ 1-l/ 7� �J / ! / <br /> lU��.,���.z� - -- - - - -- - ---- - <br /> City State Zlp~ <br /> y 7/ -�� � ------- - --- - <br /> Phone . <br /> I understand my rights as stated above. <br /> Signature <br /> BUILDING�ZONiNG—473-7357 • ADMINISTRATION db FINANCE—473•7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />