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S <br /> — _ _ _ <br /> „„,„ -2,.„.. <br /> - CITY of ®ROOT® <br /> - " .Crystal Bay,Minnesota 55323•Municipal Offices <br /> .: <br /> --,= M Post Office Box 66 ry <br /> :":-.-1:-..0E-.:-: On the North Shore of Lake Minnetonka <br /> .:y::-. - DATA PRSVACY p,Tp=SORY <br /> "Rights of subjects of <br /> 13.04 , Subd. 2, permit or <br /> In accordance with M.S. that your request for a <br /> data" , we would like to inform youof its departments may require <br /> license from the City of Orono or any <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> 1. <br /> The information you furnish will <br /> ebeeused ede to determine your <br /> cualifi cation for the permit or require that <br /> City deny <br /> • <br /> refuse to supply data, but refusal may re q <br /> the• You may the permit or license. <br /> be shared with other local , state or <br /> 3. The information may <br /> the permit or <br /> federal agencies to the extent necessary to process <br /> license. <br /> af your requested permit or licensel mayublireqCouncil action <br /> I information may become p <br /> to approve, some <br /> 5. <br /> You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> process this application or <br /> 6 . Your full name is required to p"r <br /> permit. <br /> 4 '25")A7/(4_ <br /> rfVeN Last <br /> First <br /> Middle <br /> r' r) <br /> , c9-65r 1�,��,f3f.R i LLS <br /> Address 3Y/ <br /> State Zip <br /> City � / <br /> 75-- 2 <br /> phone <br /> I understand my righ <br /> s stated above. <br /> iE <br /> 1"4" . <br /> Ln 1-'4 <br /> I` Signature <br /> I <br /> 473-7359 <br /> s 473 7358 • PUBLIC WORKS— <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE— <br /> ASSESSING <br />