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� <br /> C��� �� O���T� <br /> al Post O�ce Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> e, <br /> � _ �� � � On the North Shore of Lake Minnetonka <br /> DATA_PRIVACY ADVI_SORY <br /> In accordance with M•Shat �Iour request for a permit or license <br /> wouid �ike to inform you t y <br /> from the City of Orono or any of its departments may require you to <br /> furnish certain private or confidential information. <br /> You are notified that: <br /> l. The information you furnish will be used to determine your <br /> qual.ification for the permit or license requested. <br /> 2. You may refuse to suppZy 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 license requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 15.165 to review private <br /> data on yourself. <br /> 6. Your ful.l name, and date of birth are required to process <br /> this application or permit. <br /> ��`��`--�--��-`�--� - -----�-----� ,�--��---- ----� - ---. _�-��-�-�- ------- --� <br /> First <br /> Middle Last <br /> �l � �u 6�� ��C �;l�t� ,,Q 2 j u�P - ---- -. ..- -- - <br /> _ . ---�----- ----- <br /> Address <br /> _ - � <br /> ..U_��`'� ....------- ---.__ .--.-:".�.'-.r��''__._...--- ----- ---�-�5--�-�- ��-----�--- <br /> City State Zip <br /> --�1-��-..-._�_�"_ �.�__ --�-�------��------ <br /> Phone � <br /> I understand my rights as stated above. <br /> --- __vV`--'------._.. .--- �---- -�`-------- �- .---�----�_._--�--. .-------� -- -- ------ <br /> Signature <br /> BUILDiNG&ZONING—473-7357 • ADMINISTRAT'ION�FINANCE—473-7358 � PUBLIC WORKS—473-7359 <br /> ASSESSING <br /> 5 <br />