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� - �� <br /> � <br /> CITY of ORONO <br /> Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> i <br /> s - � ,�. 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 wou.Zd I.ike 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 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 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 privat� <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> D��G�� � ����� <br /> First Middle Last <br /> ����� ��-��� ��- ,�� <br /> Address <br /> A �-� ►� <br /> ������•�4-�`z'� �,i'.�'� � � � <br /> City State Zip <br /> L;°��,� �� � <br /> Phone <br /> I und`erstand my rights as stated above. <br /> r � <br /> - ,-, <br /> . � �. � � <br /> , . � ���y� <br /> /��i..��'"'� � 'C,�--� �""- /f� �� �--'i'� <br /> S ' gnature <br /> BUILD[NG&ZONING—473•7357 • ADM[NISTRATION&FINANCE—473-7358 • PUBL[C WORKS—473-7359 <br /> ASSESSING <br />