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. <br /> 7� <br /> �<hY+�Y+ <br /> ra.r��� ��4r�Y'*'��r,� o���� <br /> S � i <br /> �3�:�� �R�� �:_ C ITY o <br /> �4;;�r2,ki�`. w �k.f`. <br /> �� 4���•'-' a#'9.�M <br /> �� � � Post Office Box 66•Crystal Bay,Minnesota 55323•Mu��P� ��� <br /> • <br /> � _ e � On the North Shore of Lake Minnetonka <br /> DATA PRSVACY 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 confidentia3 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 license. <br /> 3. The information may be shared with other local , e�i� or <br /> federal agencies to the extent necessary to process the p <br /> 3icense. <br /> 4. If your requested permit or be ome e ub�ic res Councii ac��or. <br /> to approve, some information may P <br /> 5. 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 applicatior. or <br /> permit. <br /> �,�.t-�//�'�i� �/'S7��'r �)��-`i�� <br /> First <br /> Middle Last <br /> ,��� �� -S`'�L<� ��,�.�;c� :���c�'� <br /> Address <br /> l,�,l �;� �%l�t,� �-�.��� <br /> City � � State Zip <br /> �/�;� ,� . �/ � <br /> Phone <br /> I understand my rights as stated above. <br /> � / %�� , � <br /> Signature <br /> BUILDI\G& ZO�iING—473-7357 • ADbfINISTRATION&FINANCE —473-7358 <br /> • PUBL[C WORKS —473-7359 <br /> ASSESSIN G <br />