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� . <br /> � • <br /> ��-��+� �-f� .;' <br /> R �i�l FS� Y5h' <br /> � s� ����:;: I�Y Of OR�I111T� <br /> ''�`��r�`} � �? - � <br /> .�� �,�,� �z�� <br /> .r�� ���':. <br /> ;����I����'.�i Post Office Box 66•Crystal Bay,Minnesota 5�323•Municipa1 Offices <br /> -�,,��L� �''�'����' <br /> � . � .�- -5 <br /> : � �.�a � 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 /> license 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 �ocal, t�?� o� <br /> federal agencies to the extent necessary to process the p <br /> license. <br /> 4, If your requested permit or Iicense requires Councii. action <br /> to approve, some information may become public. <br /> S. You have certain rights under M.S. 13.04 to review pri�a�� <br /> data on yourself. <br /> 6, yauz full name is required to process this application or <br /> permit. <br /> Ko/��nr � , �- ���ss� <br /> First Middle Last <br /> :� �- ��� �°'ASc �i � /2 �L_ � <br /> Address <br /> �.r���� ���N j s� �� <br /> City State Zip <br /> 1��.�_ �7/-yz�s- — ���.z/�_ �� �3-- s��Zy <br /> Phone <br /> I understand my rights as stated above. <br /> � ; <br /> � <br /> � �� <br /> Signature � <br /> BUILDING&ZONING—473-7357 • ADMIIVISTRATIOV&FINANCE—473-7358 <br /> • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />