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� ~ <br /> � �� � <br /> :-� � � x <br /> ������ ���m � y� <br /> � �� .,� �i��� �� �R��o <br /> � . � �:: , <br /> �'A.,;` <br /> 4 �� � <br /> ��� '�� ,� � �4•`�+�,,..`� . <br /> � Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> i <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 /> 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 license requested. <br /> 2. You may refuse to suppl.y data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other 3ocaZ, state or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�e <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> 2.L'r �:"� �I'�"[v' �✓1)��I.t�C'I � <br /> First Midd e Last <br /> 2X�-�� �>S�-�:� ���E,. 1� .. <br /> Address <br /> C��yzata 1�l�.; � 1� �`1 � <br /> City State Zip <br /> �f�l ss��S <br /> Phone <br /> I understand my rights as stated above. <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINAiYCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />