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, <br /> . <br /> ,�:. - <br /> � - <br /> -� ��'�`�' o� ����T� <br /> r� �a Post Office Box 6$•C • <br /> rystal Bay, Minnesota 5a323 Municipal p{fices <br /> - 01 <br /> :� � - a g� On the North Shore of Lake l�finnetonka <br /> DATA PRIVACY ADVISORY <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 of Orono or any of its departments inay require � <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> I. The information you furnish wiil be used to determine your <br /> cuaiifica�.ion for the pe�it or Iicense r_cuest�d. <br /> • 2. You r,tay refuse to suppl.y data, but re=usal may reauire tzat <br /> the City deny the pe�-mit or Iic�nse. <br />� 3 . The information may be snared witn o�.�er ioca�, s�a�e or <br /> f edera? agencies to the extsnt necessary to process tne pe�-mit or <br /> license. <br /> 4. If your recuested per^it or Iicense _ecuires Councii ac��o% <br /> to approve, some inror.^.tation may become �ub?ic. <br /> 5 . You have cer�ain rignts under M.S. ?3 .C � to rzv_zw griv��e <br /> data on yourself. <br />= 6 . Your ful.l name is recuired to process th?s applicatior. or <br /> pe�it. <br /> ���2�-�.� � � s� , <br /> First Midd?e La � <br /> _�� 7 � ��(�w i�U� � /��ic/i� <br /> Address <br /> i ��1 �Nl� , � �/- � �.� � �l <br /> City ' State Zip <br /> _ � 7 a- -- G �'�� � <br /> . Phone <br /> � I understand my right as s`ated above. <br /> � . ' <br /> � Signature , • <br /> ILDIVG& ZONf�G — 473•73i7 • AD,tiilylSTRATfON& FIV��VCE — 473-73:3 • PUBLIC tiVORhS —473-73.i9 <br /> ASSESSIY G <br />