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� •s <br /> � � � ��'��' o� 0�.��TO <br /> Post Office Box 66�Crystal Bay,Minaesota 5532:3•Municipal Offices <br /> M . <br /> ! - <br /> On the North Shore of Lake Minneto a <br /> • ' • • <br /> DATA PRSVACY A��SORY <br /> n accordance with M.S. 13.04 , Sa�d-our request for a permit or <br /> I uire <br /> data", we would like to inform you t of its departments may req <br /> license from the City of Orono or any <br /> you to furnish certain private or coniidential inrormation. <br /> You are notified that: <br /> 1. The information you fui nor ZiCensebrequested, aetermine yaur <br /> erni� <br /> aualification for the p req�ire that <br /> refuse to supoly data, but refusal may <br /> 2, You may e�it or license. <br /> the City deny the p <br /> be snared with other Iocal , s�a�e or <br /> 3. The inf ormation may to process the pesmit oi <br /> f ederal agencies to the extent necessary <br /> Iicense. <br /> our requested permit or Iicense requyres Cou�cii ac�ior_ <br /> a. l� y become public. <br /> to approve, some information maY <br /> 5. You have certain rights under M.S. 13.04 to review griva�e <br /> data on yourself. <br /> 6, Your full name is required to proc�ss this appl.ication or <br /> pennit. <br /> � ��������� <br /> /�A�'lI� M1da�e Last <br /> Firs� <br /> r- <br /> Z �� �� (�G�-'` �/�G G� <br /> Address ���G � <br /> 1r/d �� Z ip <br /> City <br /> State <br /> � / — OSzD . <br /> Phone <br /> I understand my rights as stated above. <br /> ��1� .�,�,� ��.-..- . <br /> Signature <br /> � • PUBLIC WORiCS-473 7359 <br /> BUILD[NG&ZONiNG-473-7357 • ADMINISTRATION&FiNANCE-;73-7358 <br /> ASSESSING <br />