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- �R;v: � " � » <br /> ��� �� � <br /> � <br /> � xi . CI'�I' o� �RO <br /> :�,� <br /> �: <br /> ' � � Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> ! <br /> � _ � � 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 like 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 /> l. The information you furnish wi11 be used to determine your <br /> qual.ification for the permit or Iicense requested. <br /> 2. You may refuse to supply data, but refusa3. may require that <br /> the City deny the permit or Iicense. <br /> 3. The information may be snared with other local , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii ac�ior. <br /> to approve, some information may become publ.ic. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6 . Your full name is required to proc�ss this application or <br /> permit. <br /> � <br /> '� . f�� ��2 L�� _ _�� � ; <br /> � <br /> First Middle Last <br /> � <br /> S�i 7 s� L.�- �ti �L��� n /S L- ��-� <br /> Address � <br /> i t.. r--% i'� r—.J �� � S' �1 <br /> City State Zip <br /> �� �� �- � �_� 1 <br /> Phone <br /> I understand my rights as � ated�, abov . <br /> � <br /> l �. <br /> Signa ure � <br /> BUILDING& ZONING—473-7357 <br /> • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />