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. � <br /> z � � ����.' o� ����"� <br /> M! <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•D'1uai�apal Offices <br /> ! <br /> On the North Shore of Lake Minneton a _ <br /> o - • • <br /> DATA PRSOACY A��SORY <br /> nR1 ;1t5 Oi SllD]eCtS OL <br /> g ermit or <br /> In accordance with M.S• 13•ou`tnatdyour request for a p <br /> 3ata" , we would like to inform y o f its departments may require <br /> i.�cense from the City o= Orono or any <br /> �ou to rurnish certain private or coniidential insormation. <br /> �ou are notified tnat: <br /> 1, The inzormation you furnish will be used to determine your <br /> aual.ification for the per,ni.t or 11cense requested. <br /> 2. you �ay refuse to SL1PP1'i`�o�se,but reTusal may require that <br /> tne City deny tne pe�i�- �r <br /> 3 , The information may be snare ss�thto proc sscthe pe'-�nie or <br /> f ederal agencies to the extent nec Y <br /> ?icense. . <br /> �-od pe�nit or Iicense requ�res Councii ac��o% <br /> a. �f your reques�._ become public. <br /> to aporove, some iniormation maY <br /> 5 , You have certain rights under M.S. 13.Oa to review griva�e <br /> data on yourself. <br /> 6 . Your full name is recuired to proc�ss this appl-ication or <br /> per:nit. <br /> c ' � � - : <br /> � ; ; <br /> � � Lds�. <br /> irst Middle <br /> � - �; L IJ C� - � <br /> � . <br /> Address <br /> , _ - -- i <br /> � � �' ��' State Z1p <br /> City <br /> y7�� � � U % <br /> Phone <br /> I understand my rights as stated above. <br /> -� -- , ; ;. ., _ a <br /> �� c� �� �� , � . <br /> ignature � <br /> 3UILDING&ZONING-473-7357 • ADMINISTRATION&FtNANCE-;73-7358 <br /> • PUBLIC WORKS-473-7359 <br /> pSSE55ING <br />