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r + <br /> .y <br /> � <br /> c�TY o� oRONo <br /> Post Office Box 66•Cryatal Bay,Minnesota 55323•Municipal Officea <br /> • <br /> � _ � � On the North Shore of Lake Minnetonka <br /> D1��'�1r�$�CY ���QR� � <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> wou2d 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 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 /> 3icense. <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 /> � <br /> lZj,� . ----�--- 1��--�-�--�� -`�--�- -.--- . __. . . �'-��-- -----_._...._. <br /> First Middle Last <br /> � � �� �' • --- <br /> Address � r--� <br /> _ . . .. _ . �--- ._ _.- - �-�-._.. .. _ __ --�--- �--------------�...._�-- ---•-----�--- <br /> ity State Z1p <br /> 7.� �.�� . - <br /> Phone <br /> I understa m rights as stated above. <br /> r <br /> � . <br /> Si ^ ture <br /> BUILBING&ZONING-473-7357 • ADMINiSTRATION&FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />