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..r 1 <br /> � RONo <br /> CITY of O <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> � _ � � Orc the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of sub eerc�ts� o�� <br /> data", we would like to inform you that your request for a P re uire <br /> license f rom the City of Orono or any of its departments may Q <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> l. The information you furnish will be used to determine your <br /> qualification for the permit or Iicense 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 Iocal , s�ate or <br /> f ederal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or 3.icense �equires Councii ac��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 full name is required to process this application or <br /> permit. <br /> �r�^.2� T��('� � y� <br /> First Middle La�� <br /> �k y � �.r��� n �.2_, <br /> Address `� <br /> ���- �� k,� 1'`'�r�l ,�530 S <br /> City State Zip <br /> SyS -�I6� <br /> Phone <br /> I understand my rights as stated above. <br /> �Gl�� <br /> Signature � <br /> BUILDING&ZON(NG-473-7357 • ADMINISTFtATION&FINANCE-473-7358 <br /> • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />