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'�-"1 X , z���y� . <br /> �� �' <br /> � I � ' <br /> : `� �- � CI'T'Y of OROl\T(� <br /> y �'— '°� - ,. <br /> �.� ,: <br /> � ��:: � ,:; •; <br /> F ��,�-�� � # Post Office Box 66•Crystai Bay,Minnesota 55323•Municipal Offices <br /> '' "`����'"u''n i + i�; <br /> � _ � '�;�,;' On the North Sh.ore 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 confidentiaZ 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 Iicense. <br /> 3. The information may be shared with other iocal , 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 Counci3 action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�� <br /> data on yourself. <br /> 6. Yaur full name is required to process this applicatian or <br /> permit. <br /> � � �_ �t'/- � � - <br /> I>,_. �. ' `- % ��ti� L - � <br /> First Middle Last <br /> � �`�-�� �� � � �C- C, � 2 C_,L i_.. <br /> Address <br /> ��i;a ,' �? �.� %A ��" ��'�� `.�� �� `%� <br /> City State Zip <br /> �: ;'�' - �/ �=' i' � <br /> Phone <br /> I understand my rights as stated above. <br /> / ) _�' �c �'� ___ <br /> � � ��%` <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION 8c FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING ° <br />