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` � ����' o�� ���i�� <br /> � Posc Office Box 66•Crystal Bay,Mianesoca a5323•Municipal Officcs,� <br /> •1 <br /> � _ �' , �, On the iVorth Shore of Lake Minr�etonka <br /> DAT�_PR�VACY ADQISORY <br /> In accordance with M.S. I5.165 , "Rights of subjects of data", we <br /> wou�d like to inform you that your request for a permit or Zicense <br /> from the City of Orono or any of its departments may require you to <br /> furnisn certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine yvur <br /> qualification for the permit or license requested. <br /> 2. You may re=use to supply data, but refusal may require that <br /> the City deny t:�e permit or license. <br /> 3. The information may be shared with other Ioca2, state or <br /> federal agencies to the extent necessary to process the permit or <br /> I.icense. <br /> 4. If your recuested permit or Iicense requires Council action <br /> to an�rove, some infor.nation may become public. <br /> 5. You have ca=tain rignts under M.S. 15.165 to review private <br /> data on yourse�� . <br /> 6. Your full name, and date of birth are required to process <br /> this application or permit. <br /> : � �`�—7-�/���� ��,�;L� <br /> .��:. . ---------- - _ -- - �- - ---. .- -�-- �• ---------•---- <br /> . d�/` i= -- '�/�;_�-•-- <br /> First Middle Last <br /> . <br /> G�i� ���,�,;z���r�_�---.- '_<.� �/:=�- ==-.--��:-�-�� - �---_.... . _. .. ._ <br /> �7- 7. .�--• <br /> Address <br /> ��� � � - ���i�., - -- -- - � <br /> .. <br /> City State Z1p <br /> ����- - l��'7' --- --- -- - : <br /> Phone � <br /> I understand my rights �as stated above. <br /> � ,� � <br /> �^..0 c' ✓' ` � � � <br /> �;, _ - - . - - <br /> Signature � <br /> BUILDING�ZONIIVC—473-7357 • ADMINLSTRATION�FlNANCE—473 7358 • PUBLIC WORKS—473 7359 " <br /> ASSESSING • <br /> 5 <br /> --....�..,..�-�;.�,�.....��.,.:.;....,.,....,.� ._...►a...--. ..._.. ._ . �.� . . . . .--- _ —___-�.__ ...__ .� . ._ . <br />