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� <br /> CITY of OR�NO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> � . � � On the North Shore of Lake Min.netonka <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we would Iike to inform you that your request for a permit or <br /> Iicense from the City of Orono or any of its departments may require <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish wi3.l 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 Iicense. <br /> 3. The information may be shared with other Iocal , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii action <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 full name is required �o process this application or <br /> permit. <br /> � G�Lr E.R- � Q C�- s�� <br /> First Middle Last <br /> 3 I 3� � 3 oTN A� �- N �..� <br /> Address <br /> C� oo c� QZ�� �n5 M N 5 5 �4 �r � <br /> City State Zip <br /> �-4-�.� - � �. g 3 <br /> Phone <br /> I understand my rights as stated above. <br /> �/ <br /> Sign ure , <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />