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` � , <br /> ��.,, �`�� �, :�� <br /> a� <br /> n�t��ax���l y���':;� �I'�Y o� ORON� <br /> � �£�C�a�.Y t� y'� <br /> #�:.��r �:-`� } 1 <br /> �:-. � '`=R +° �' ;-$ . Minnesota 5a323•Municipal Offices <br /> G��_ _ �i Post Office Box 6fi Crystal Bay, <br /> • � '"' <br /> • - • • <br /> ���" On the North Shore of Lake Minnetonka <br /> DATA PRNACY A�VISORY <br /> In accordance with M.S. 13.04 , Subd. 2 , "Rights of subjects of <br /> data" , we would like to inform you that your request for a permit or <br /> license from the City <br /> 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 ulled ed, aetermine your <br /> qualification for the permit or Iicense req <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 oth��r e scthe permit or <br /> federal agencies to the extent necessary to p <br /> license. <br /> a. If your requested permit or Iicense requires Councii. ac�ior. <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6 , Your ful.I. name is required to process this application or <br /> permit. <br /> -��,����i �� .���L/��'',P/J S �'J <br /> First <br /> Middle Last <br /> 0 i3 � � � � <br /> Address <br /> lC�� S� ;�Z— /�:�'l <br /> I/j/.� �>>-�� � <br /> City State Zip <br /> ��^ '-� /leLo� <br /> x�� , <br /> Phone <br /> I understand my rights as stated above. <br /> a�!�'� /1 <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADM1NiSTRATION&FINANCE —473-7358 <br /> • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />