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� � <br /> �, ;:a�,� � <br /> f� g�iT�+��,.. ��.��i' <br /> f� ;�h�' t:e .�,. <br /> r �.��:���� ������ �ay� C ITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> � _ � � On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> In accordance 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 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 Iicense 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 I.ocal , state 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 pri�a�� <br /> data on yourself. <br /> 6. Yaur full name is required to process this applicatian or <br /> permit. <br /> �--- <br /> ►-}��ti.���� ���� �-t�L�c'��.''1`i 1 <br /> First Middle Last <br /> ---��:� �.;,r_���.� -���- _"�-' . <br /> Address <br /> �'1 i��=-' Y`'r� `�=�'`�� <br /> City State Zlp <br /> ��77- �' 7���` <br /> Phone <br /> I understand my rights as stated above. <br /> , <br /> . ..—._____> � , <br /> - i F--��-�� z ,�� -L-L� <br /> Signature <br /> BUILD[NG&ZONING—473-7357 • ADMiN[STRATION&FINANCE—473-7358 • PUBLiC WORKS—473-7359 <br /> ASSESSING <br />