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,�,.,t'ri:,.e�. <br /> - �,='r:- <br /> ^�►�`��"� '� <br /> ... - � � ��.� <br /> F <br /> t ^u <br /> ..�.c�73.�!��i�+`, � 5�.^L <br /> � �i��� O� ����� <br /> :�.r� �' �,� <br /> ^n A _ <br /> ��t.I� `'� �� ���}�a <br /> t,::-.�� Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> ,�.-r--::•�; <br /> "��a`ao'= <br /> 0 .-f `� <br /> e _ � 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 wi3.1 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 , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or I.icense requires Councii actior. <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�e <br /> data on yourself. <br /> 6. Your full name is required to procass this application or <br /> permit. <br /> r 'q� �rrra� � <br /> First <br /> Middle Last <br /> ��o� �'�a i�� - <br /> Address G�� <br /> h � ( <br /> Cit State Zip <br /> %J��dB� <br /> Phone <br /> I understand my rights as stated above. <br /> � <br /> �Qi� G�(/YlOyr <br /> Signature � � <br /> BUILDING&ZONING—473-7357 <br /> • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />