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.. - ,. <br /> � <br /> C ITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offic�s <br /> • <br /> � _ � � On the North Shore of Lake Minnetonka <br /> D�1Tj! ���AC�.ADV��RY , <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 confidentia3 information. <br /> You are notified that: <br /> l. 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 I.icense 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 /> �i cG�Q t`-�� --C�--�-----..�.--- _'.�=!:J. . .-G f�.�!_J----- ---- - <br /> First Middle Last <br /> -���,� �� ��o r-� �r(— ---_ . .- - -- ._, <br /> Address <br /> � <br /> .-----,1/�o c�'-`�------ ._ _.- - ---._.._.�� _ S S�1_�/------�--- <br /> � <br /> City State.__._ - ------Zip <br /> __ ..._._�.�. 7._./_._�-__��a-.�l___._-- -----._------- <br /> Phone <br /> I understand my rights as stated above. <br /> ignature <br /> BUILI3ING&ZONING—473-7357 � ADMINISTRATION 8c FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />