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` T� , �� <br /> L.,c ��(� ;7..,, <br /> �:V <br /> .-� v��$ � a�' <br /> �� �` � ���� C ITY of ORONO <br /> � �aa-,�.,t x�, <br /> ,`��� n��; a <br /> �'.� ''� '�n�'»x.#.�;:.. <br /> �' � �`� ' Post Office Box 66•Crystal Bay,Minneaota 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 /> 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 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 permit ar <br /> license. <br /> 4. If your requested permit or Iicense requires Councii. actian <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 ap�.•licatica o� <br /> permit. <br /> ���. . <br /> First Mid le Last <br /> l��O� �Dt-f`�, �rtT� J�G�' <br /> Address <br /> ��-- /�'l� �5 � <br /> Cit State Zip <br /> ���' �-l[."� <br /> Phone <br /> I understand my rights as stated abov . <br /> Signat re <br /> BUILDING&ZONING—473-7357 • ADMINISTRATIOIV&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />