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K <br /> µ4 <br /> A,.- i��-�" r�•: -�. �";� ..uy <br /> �;�.� � �i��Y O� ���N� <br /> r� � '' �''� ` �'�"f� <br /> �.,�5.��'z4 T,i::F`�;.. <br /> :=E•i <br /> -� . Minnesota 55323•Municipal Offices <br /> Post Office Box 66 Crystal Bay, <br /> � <br /> � _ o � On the North Shore of Lake Minnetonka <br /> DATA PRIVACY A�VISORY <br /> In accordance with M.S. 13.04 , Subd. 2 , "Rights of subjects of <br /> data" , we would Iike to inform you that your request for a permit or <br /> Iicense from the City of Orono r conf dent al e nf rmationmay equire <br /> you to furnish certain private o <br /> You are notified that: <br /> l. The information you furnish will be used to determine your <br /> qualification for the permit or Iicense 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 he extenthnecessaryhtotprocesscthe permit °r <br /> federal agencies to t <br /> license. <br /> 4, If your requested permit or I.icense requires Councis a��'-or <br /> to aporove, some information may become public. <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 /> ScM � `� <br /> ���������� ��� I � �� <br /> Middl.e Last <br /> First ,� <br /> � � C 7 �-s �� �1 � �� - - <br /> Address � _ <br /> C�� � ct �1. � � ,� � <br /> ^ State Zip <br /> City <br /> � 7 �- � 77 � <br /> Phone <br /> I understand my ,rights as stated above. <br /> / � � <br /> ; �z_ � �%��. <br /> � <br /> Signat e <br /> � <br /> i <br /> BUILDING&ZONING—4�3-�357 • ADMINISTRATION&FINANCE—473-7358 <br /> • PUBLIC�'ORKS —473-7359 <br /> ASSESSIY G <br />