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.• ' <br /> � '` <br /> C ITY of ORON� � <br /> �I Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Officea <br /> • <br /> • - � • �i On the North Shore of Lake Minnetonka � <br /> DATA PRNACY ADVISORY <br /> In accord�nce with M.S. 13.04,. Subd. 2, "Rights of subjects of <br /> data", we would like to inform you that your request for a permit or <br /> license from the City of Orono or any of its departments may require <br /> you to furnish �ertain private or confidential information. <br /> You are no ified that: <br /> l. The in ormation you furnish wi3.1 be used to determine your <br /> qualificat on 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 in,formation may be shared with other local, state or <br /> federal ag�ncies to the extent necessary to process the permit or <br /> Iicense. ' <br /> 4. If you� requested permit or Iicense requires Council act�on <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�e <br /> data on yourself. <br /> 6. Your f�all name is required to process this application or <br /> permit. <br /> o ��G� 4 .UoH� ,��c C��( e'� <br /> First Middle Last <br /> � � � X 7�e� �d`, � a � S �v��e., <br /> Address <br /> �b� (�-I�/1 � ��� � .� ��.S �P <br /> City � State Zip <br /> G/7� ' %0� `7 <br /> Phone <br /> I understand my rights as stated above. <br /> � <br /> i � <br /> Signature , <br /> BUILDING&ZONING—473-735p • ADMINISTRATION 8c FINANCE—473-7358 • PUBLIC WORKS—473J359 <br /> ASSESSING <br /> i <br /> I <br />