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. �.�.. <br /> � <br /> CITY of OR4N� <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 /> 1. The information you furnish wi3.l be used to determine your <br /> qualification for the permit or Iicense requested. <br /> 2. You may refuse to suppZy data, but refusal may require that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with other Iocal, state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or license requires Council action <br /> to approve, some information may become publ.ic. <br /> 5. You have certain rights under M.S. 13.04 to review priva�e <br /> data on yourself. <br /> 6. Yaur full name is required to process this apFl.icatian or <br /> permit. <br /> ��.vn��5 �7aP o�fi..J '�.�F���+S t� <br /> First Middle Last <br /> '�--r. � 4 �3 au ��s <br /> Addr� <br /> �.� �-r r ��v, 550 4 a <br /> City State Zip <br /> Q.4-q.�-53 s'3 <br /> Phone <br /> I unders my ri hts as stated above. <br /> Signature , <br /> BUILDING&ZONING-473-7357 • ADMINISTRATION&FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />