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� . .. <br /> �-�,, '��� � ; ; <br /> q ���� '� <br /> l� � CITY of ORONO <br /> ! -..Ml'�i �"1 <br /> qa :� � <br /> �3 dt3 <br /> �ul.,+i'D�.� w <br /> ,�-: <br /> Y d •" '. <br /> r 3i Post Office Box 66•Crystai Bay,Minnesota 55323•Municipal Offices <br /> • - ` `�7 <br /> • - • „'�o` On tlze Nortlz 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 Iike to inform you that your request for a permit or <br /> Iicense from the City af 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 wil.3 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 , state or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Counci3. action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�� <br /> data on yourself. <br /> 6. Yaur full name is required to process this applicatian or <br /> permit. <br /> �� ���� <br /> First Mid le Last <br /> 30_�� P��. � 5 - <br /> Address <br /> SLp � � Ss�/�� <br /> City State Zip <br /> 6/� %�� 6�/�/ <br /> Phone <br /> I understand my rights as stated above. <br /> r <br /> Signatur <br /> BUILDING&ZONING-473-7357 • ADMINISTRATION&FINANCE-473-7358 • PUBLIC WORKS -473-7359 <br /> ASSESSING . <br />