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�r►. � <br /> ` ONO <br /> CITY of 4R <br /> Post Office Box 66•Crystal Bay,Minnesota 553?3•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 wi31 be used to determine your <br /> qualification for the permit or license requested. <br /> 1 data, but refusal may require that <br /> 2. You may refuse to supp y <br /> the City deny the permit or license. <br /> 3. The information may be shared with ot�ocesscthe permit or <br /> federal agencies to the extent necessary to p <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 ful.l name is required to proc�ss this application or <br /> permit. <br /> ��a�y,�1 � �/�.��� <br /> First Middle ' Last <br /> .3 � 5' � S'.S/6/z�t �i�� ��- <br /> Address <br /> �iS�Y-�.97'� �'n i� �S 3 S'� <br /> City State Zip <br /> �7/-- 8�S 6� <br /> Phone <br /> I understand my rights as stated above. <br /> . �� � <br /> S ure <br /> BUILDING&ZONING—473-7357 • ADMINISTRATIOIY&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />