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_ � <br /> � (��'��" o� O�t�I�TO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> • _ � � Orc the North Shore of Lake Minnetonka _ <br /> DATA PRSVACY ADVISORY <br /> In accordance with M form3•ou�that your request for a perm t or <br /> data", we would like to in y o f its departments may require <br /> license from the City of Orono or any <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> l. The informati�heY e�t or li ensebreque tea. determine your <br /> crua1ification for P <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the perntit or license. <br /> 3. The inf ormat��o the extenthnecessary to processcthe permit or <br /> federal agencies <br /> ?icense. <br /> 4. If your requested permit�ar become p blic.res Councii ac��or. <br /> to approve, some information y <br /> 7. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your full name is required to proc�ss this application or <br /> pennit. <br /> 2�c��/�' <br /> � � Last <br /> First <br /> Middle � <br /> S�' �i S�— „���_—s �"' � <br /> T <br /> Address . <br /> � � � <br /> a v rJ <br /> City State Zip <br /> 7/- S/.�� <br /> Phone <br /> I understand my rights as st ed above. <br /> ignature � � � <br /> BUILD[NG&ZONiNG—473-7357 • ADMINISTRATION&FINANCE—473-7358 <br /> • PUBLIC WORKS—473-7359 <br /> pSSESSING <br />