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�_�� <br /> +'a :-_x�i1��3 <br /> �� x3 <br /> ".���-�r�abe�cac�=.TH.-.a <br /> _—mr��a,a� � � <br /> � �t�y� �� �� �, � ��� ����-�� <br /> � a <br /> "'' f Yost Office 3ox 66•Crystal Bay, t4linnesota 5�:s2:i•i�lunicipal Ufhces <br /> i <br /> � .:�� ��� On the North Shore o}'Lake Mi,�retor�a <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 /> I.icense 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 Iicense requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other Iocal , state or <br /> federal agencies to the extent necessary to process the pern�it or <br /> license. <br /> 4. If your reauested 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 prica�� <br /> data on yourse�f. <br /> 6. YGll� fliil. ;a8;:� s-S �aC'.�'=.'-=�=� �n rrOCASS t!Z1S 3D�11.CaL1021 OT <br /> permit. <br /> �- J� s� �' <br /> �� p✓r� J 1� .�r /` I �_ /G r�✓'►'� ✓ <br /> � ... �,T ' .±r,� � T z S t <br /> L 11JL. 1"'�_� <br /> (�j� � Pa c1�i- �- ���� <br /> Address <br /> � ���-� /�I �'- `� 5 � / � <br /> City State Zip <br /> ��� �' l (�>/ 1 c�J'� C-� ��-� —�� J7 <br /> Phone <br /> I understand my rights as stated abo IE R NAN <br /> - NSTRUCTION <br /> Signature TIMOTHY KIERNAN <br /> BUILDER <br /> BUILDING&ZONING —�373-7357 • ADMINISTRATION&FINANC! <br /> 814 43RD STREET WEST,MINNEAPOLIS,MN 55409 <br /> ASSESS[NG SHOP—825-1611 HOME—825-0053 <br />