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i <br /> ......... ........ CITY®f ORONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323+Municipal Offices <br /> 0 <br /> ® _ ® On the North Shore of Lake Minnetonka <br /> In ccordance with M.S. 15.165, "Rights of subjects of data", we <br /> would l�ke 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 /> Yo are notified that: <br /> 1. The information you furnish will be used to determine your <br /> qu lification for the permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> th City deny the permit or license. <br /> 3. The information may be shared with other local, state or <br /> fe era l agencies to the extent necessary to process the permit or <br /> li ense. <br /> 4. If your requested permit or license requires Council action <br /> t approve, some information may become public. <br /> 5. You have certain rights under M.S. 15.165 to review private <br /> d to on yourself. <br /> 1 <br /> 61 Your full name, and date of birth are required to process <br /> tiis application or permit. <br /> First Middle Last <br /> Address <br /> ity State p <br /> Phone <br /> understand my rights as stated above. <br /> 7gn—iture- <br /> BUILDING <br /> & ONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />