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. <br /> .. <br /> � <br /> CITY of ORONO <br /> Post Office Box 66•Cryatal Bay,Minnesota 55323•Municipal Officea <br /> Y <br /> � _ � . On the North Shore of Lake Minnetonka <br /> D�1�� �R�VACY A�DVV�SORY ' <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 inf ormation you f urni sh wi 1 I be us�d to determine vour <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 /> 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 /> b. Your full name, and date of birth are required to process <br /> this application or permit. <br /> _ ..L�s_.�Qn��_. AQ4�.?�n �_.. Inc,._ ----. ....---- - . ._-------�----- --�--- <br /> First Middle Last <br /> -----941__W.. .80th.. S.t- ..----...._ .._ --�-----------�..__.__._ ..__ ._. ------ _ .. ... _. ._- <br /> Address <br /> Bloomington, MN 55420 _ .. <br /> ._._. ....-----. ..------------- --- __.._...._._. .----� .--.-- -- - -------_..._.------..__ - -- <br /> City State Zip <br /> 881-2241 _ <br /> -- .__..... ...._ .__.._.._. <br /> Phone <br /> I understand my rights as stated above. <br /> � --�----__ --- -------- - <br /> ignature <br /> BUILD[NG&ZONING—473-7357 • ADMINISTRATION 1&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSFSSING <br />