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� � <br /> ,�:- - <br /> '-�= �. � - <br /> �-`� ��'��.'o� ����T� <br /> �� Post Office Box 66•Crystai Bay,Minnesota 5a323•Municipal Qffices <br /> 0 <br /> : � - � g i On the North Shore of Lake ll�finnetonka <br /> DATA PRIV�CY ADVISORY <br /> In accordance with M.S. I.3.04, Subd. 2, "Rights of subjects of <br /> data", we would Iike 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 wi�I be used to determine your <br /> quaiiiication for the pe�-.nit or Iicense re�uested. <br /> 2. You nay refuse to supp?y data, but refusal may require t'�at <br /> the City deny the permit or license. <br /> 3 . The information may be snared witn o�.zer loca? , s�a�e or <br /> f ederal agencies to the extent necessary to process tne pe?-mit or <br /> ?icense. <br /> a. If your requested per•r.it or Iicense =ecuires Councii ac��o% <br /> to ap�rove, some infoz-^tation may become public. <br /> 5 . You have certain rignts under M.S. 13. C? to rev_ew priva�e <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> pe�-mit. <br /> �� f7�) .�/�'��•rS C�Y� G'L�6�/�7rt Ci�-� <br /> First Middle Las� <br /> �_��7 U � /� �"l^� /�,� <br /> Address <br /> � , <br /> ...Q i�r l-��.� ✓Yz ,'� ��-�� ��_�� <br /> Czty State Zip <br /> � �� -� ��� <br /> Phone <br /> I understand my rights as stated above. <br /> _ �.. _ <br /> Sig�ature . � <br /> Bll1LDING& ZOVI�G —473-7357 • AD,�IINISTRATION.4c FIVAVCE — 473-73_3 • PUBLIC IVORKS —4'3-7359 <br /> ASSESSIY G <br />