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f ' <br /> ` � <br /> � <br /> C ITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal OfScea <br /> • <br /> o . � A On the North Shore of Lake Minnetonka <br /> DA,T�f, �R�VAC7�.2�DQ��9�� � <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 /> h9A,G7� $• S�f'it� �da,�' .7�2�(00 <br /> First Middle Last V <br /> �Z3.�' ��.Iv� ��. - .----_ __._ .- - -- .._ <br /> Aaaress <br /> G��yz�r'�1 I'r�1� ,��`�'1 -- -- - ---- - <br /> City State Z1p <br /> . <br /> 6f'L �T,�'___3l�__..--�-�------...------ <br /> Phone <br /> I understand my rights as stated above. <br /> � ._ ..__._----.._. .----� ---------- <br /> Signature <br /> BUILI3WG&ZONING-473-7357 • ADMINISTRATION 8c FINANCE-473-7358 • PUBLIC WORKS-473•7359 <br /> ASSESSING <br />