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�` R <br /> ���� � <br /> �- �� C ITY o� OR�NO <br /> �: <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 Iike to inform you that your request for a permit or <br /> Iicense 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 /> l. The information you furnish wil.l 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 3icense. <br /> 3. The information may be shared with other Iocal , s�ate or <br /> f ederal. agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or I.icense requires Councii. ac��or. <br /> to approve, some information may become public. <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 process this application or <br /> permit. <br /> � .��-���� �����-�.l <br /> '� ��''� Last <br /> First Mi dIe <br /> ��.> 1 ,�� � ��`� /'�' <br /> Address <br /> `�_ ..S�S-�3 i� <br /> ,,�;2 � ��- <br /> Cit State Zip <br /> �J� .���- � ,s� <br /> Phone <br /> I understand my rights as stated above. <br /> �, , <br /> �-,, ,, �z t,s:�i� _ <br /> �" �Z�e�(� , <br /> Signature � <br /> BUILDING&ZONING—473-7357 <br /> • ADMINISTRATION&FINANCE—373-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSIN G <br />