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. <br /> � <br /> � � <br /> CITY of 4RON4 <br /> Post Office Box 66•Crystal Bay,Minn�ota 55323•Municipal Officea <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 confidentiaZ information. <br /> You are notified that: <br /> 1. The information you furnish wil.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 3icense. <br /> 3. The information may be shared with other �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 Council 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 /> o�t�-*� -�-0 �,-� <br /> First Middle Last <br /> 2� 4 3 �9 T�s�, ,.�.L, <br /> Address <br /> � �=�� M � ..��-313 <br /> City State Zip <br /> � I Z �� �-- 3 3 b�1 <br /> Phone <br /> I understand my rights as stated above. <br /> � .,�1-r-�--� G�"� <br /> Signature <br /> BUILDING&ZONING-473-7357 • ADMIIVISTRATION&FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />