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1 <br /> � <br /> � � (��[�"�' o� ��►(�N� <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Muaicipal Offices <br /> ! <br /> � _ � � On the North Shore of Lake Minnetorcka _ <br /> DATA PRSVACY ADVISORY <br /> In accordance with M.S. 13•ou'that your request for a perm t or <br /> data", we would like to inform y re uire <br /> license from the City of Orono or any of its departments may Q <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The informati�hey ermitnor li ensebrequested. determine your <br /> qualification for P <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The inforraat�o the extenthnecessaryhto processcthe perntit or <br /> federal agencies <br /> license. <br /> 4. If your requested permitmar become p b�� res Councii ac��or. <br /> to aporov e, s o m e i n f o r m a t i o n y <br /> 5. You have certain rights under M.S. 13.Oa to review private <br /> data on yourself. <br /> 6. Your full. name is required to procsss this application or <br /> pe�-mit. <br /> 1� - �S <br /> �l� Middle Last <br /> First <br /> 1 �-i �c� C � 2-� � � <br /> Address <br /> �� ��--,.��I� � � <br /> City <br /> State Zip <br /> �-�� � - o��� <br /> Phone <br /> I understand my rights as stated above. <br /> \ . <br /> Signature ' � � <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 <br /> • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />