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- � � <br /> � ���� <br /> �I''1'Y Of O <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 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 confidential 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 license. <br /> 3. The inf ormation may be � neces aryhto pr cesscthe permit or <br /> federal agencies to the exten <br /> license. <br /> 4. If your requested permit or Iicense requires Councii action <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 procass this application or <br /> permit. <br /> (� /�,_.) �e f'�.'o� <br /> J� c � <br /> First Middle � Last <br /> 3�� �U �'�� � ./��, v .e <br /> Address � <br /> ��o � � �ti S'�3� y _ <br /> City � State Zip <br /> � 7�– 5��� <br /> Phane <br /> I understand my rights as stated a ove. <br /> � — <br /> Signature • ' <br /> BUILDING&ZONING-473-7357 • ADMINISTRATIO[Y&FINANCE-�173-7358 • PUBLIC WORKS-473•7359 <br /> ASSESSING <br />