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� _. , <br /> d ���. <br /> �� � CITY of ORONO <br /> z Xw.� w <br /> ._��-", ...�, <br /> k� .s,c+-'.. <br /> 3 � . <br /> ��;• Post Office Box 66•Crystal Bay,Minneaota 55323•Municipal Officea <br /> 3 <br /> � - � � On the North Shore of Lake Minnetonka <br /> DATA PRNACY 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 /> 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 /> 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 licensee <br /> 3. The information may be shared with other Iocal, state or <br /> federa]. agencies to the extent necessary to process the permit or <br /> Iicenseo <br /> 4. If your requested permit or Iicense requires Council action <br /> to approve, some information may become public. <br /> 5o You have certain rights under M.S. 13.04 to review privat� <br /> data on yourself. - <br /> 6. Your full name is required to process this application or <br /> permit. <br /> �� ���`��l�' ��'�j/�C%F� f ��`�, Y�/?/..�/�'�,/� <br /> First Middle Last <br /> l7 r���i; � _J .;� r„ �,t,,`- J ��`;,�ip � <br /> _ � <br /> Address <br /> �—;,- <br /> �"�'/�,._;' i���=-� .l ..i' �� �� <br /> City State Zip <br /> > <br /> � -'f" i' �%;<; �/-'1,'��.= � <br /> ' � <br /> Phone <br /> I understand my rights as stated above. <br /> �� ��`� > <br /> � .<.�l - i�;�-� �,� <br /> Si ature <br /> BU[LDING&ZONING—473-7357 • ADMIN[STRATION&F[NANCE—473-7358 � PUBLIC WORKS—473-7359 <br /> ASSESSING <br />