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� <br /> (��'�'�o� ���1�T� <br /> A1 Post Office Box 66�Crystal Bay.Minnesota 5�323•Mnnicipal Offices <br /> • <br /> � _ � �. On the North Shore of Lake Minrcetonka <br /> DATA PRIVACY AD��ORY <br /> In accordance with M.S. I5.165, "Rights of subjects of data", we <br /> wvuld Iike 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 /> 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� ra1 a enciestto the extenthnecessary to processcthe permit or <br /> fede g <br /> 3.icense. <br /> 4. If your requested permit or license requires Council action <br /> �b approve, some information may become publ.ic. <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 permi.t. <br /> � ,• �I��1���.- --- - ----�_ � �� <br /> V��z.��N_ - - -- -F- ------- - - � -- <br /> _ _ _ ..___.. ._. . .- - <br /> .. .. ..---•�--------- . __..._.�.. .. _.. Last <br /> First Middle <br /> �� � �"' �Ylv w�do�.� �Z v�.�. F ---_.... .. ._- -- -- <br /> Address <br /> �'1ovN� � N � �5��� ----- - - - <br /> City State Zlp <br /> �7 � '� ���1---- - --- - - � <br /> Phone �... <br /> I understand my rights as stated above. <br /> Siqnature <br /> BUII.DING�ZONIIYG-473 7357 • ADMIIv1STRATION�FiNANCE-473-7358 � PUBLiC wORKS-473-7359 <br /> pSSFSSING <br /> 5 <br />