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w <br /> .-r, k''� <br /> 'Y R <br /> iF CITY of ORONO <br /> ° a ;• Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> ."4-, .,,, On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <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 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 /> 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 /> &hard .____ . -__. ki2k'Jcvq--- - __ --- <br /> First 1 Middle Last <br /> 4-17 -_- __kbt_th. . .s�)(14)re_ - 11_,t-,L. .. - - _ . .. ._....- <br /> Address <br /> n;2_011. r) 1hAJ <br /> - ').1 ab ci <br /> City <br /> -._-------.-- <br /> State Zip <br /> 4 <br /> Phone <br /> I understand my rights as stated above. <br /> -,--r-T.‘"P.C,2_ 17.,24- _ _. _._..__. . _.__._ _..._ <br /> Signatur <br /> BUILDING&ZONING-473-7357 • ADMINISTRATION&FINANCE -473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />