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J� � <br /> � O <br /> c ITY o� oRON <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 /> 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 will be used to determine your <br /> qualification for the permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with other local , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii ac�ior. <br /> to approve, some information may become public. <br /> �. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your full name is required to proc�ss this application or <br /> permit. <br /> T� � <br /> ,�'.`��..- <br /> First Middle Last � <br /> � � � �0 <br /> 3 � <br /> Address ������� ��� � � t �� <br /> �U`=�� .�_ <br /> City State Zip <br /> � �3- � �.�� <br /> Phone <br /> I und tand my righ s as stated above. <br /> / <br /> � <br /> Signature � <br /> BUILDING&ZON[NG-473-7357 • ADMINISTRATION&FINANCE-473-7358 • PUBLIC WORKS -473-7359 <br /> ASSESSING <br />