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� � <br /> �,� � . , <br /> , � , <br /> �:�� �� <br /> �`�}`�'x�-��` ��� CITY of ORONO <br /> .Y-*'� s "'' <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 /> 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 will 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 information may be shared with other local , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii actior. <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 /> �,��/r-n��=i"� <br /> n r C V'. � <br /> �� �_� 1�J ( i ��. � ` \ . . ( - �fa1�{' ... '- '�...` j�4:�r�- �- , . �- . � - i. -. .J�d-_ _ <br /> First Middle Last <br /> --� �,. <br /> t7cy l-1 C � <br /> Address <br /> , - ,��'\ ,�, _ ' -; . , 3 <br /> � �..;���- , <br /> �� �� `�`, 7"z- � _ ' <br /> City State ' Zip <br /> � -:� T- . ; - "" :' 4' ,y <br /> y <br /> �t � , <br /> Phone <br /> I understand my rights�as stated above. <br /> � <br /> �/ ,� <br /> � ' . - <br /> � � � /Ui�6�,�-r..�"� <br /> �:� .�. <br /> Si`g�a ure � <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSIN G <br />