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. <br /> r 4 , <br /> • �y�.'1*R. fi N, / t '4'�.T <br /> '`�r a'�.. - <br /> A� <br /> � <br /> 4,� � .M�� � . � :� C I'�Y of OR��T� <br /> � r.a � � �-rs- <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 Iike 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 /> l. The information you furnish will be used to determine your <br /> qualification for the permit or Iicense 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 , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�� <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> . /� , � <br /> . , ' ; ���.�� /� <br /> � � 11� � <br /> F rst Middle Last <br /> �l h � �'" �, � �.C /`� � � ^ , <br /> Address —� ~ <br /> l�.-P n i,� 1,1(�� t���t -�� s"� �� _ <br /> City State Zlp <br /> L� � �'� � � C�.�/� <br /> <� )�n <br /> Phone <br /> I understand my rights as stated above. <br /> � ) � <br /> ,�� <br /> ! ��` �-�' �%i�� �%, %I��'`1��%� ;�. <br /> Signature <br /> BL`ILDI:�G&ZOVI�IG—473-7357 • AD�tINISTRATION&FItiANCE—473-7358 • PUBL[C WORKS—473-7359 <br /> ASSESSI`G <br />