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Y <br /> � ; , t <br /> 1lr�fnl a� (4�f)6 t.r <br /> � "� <br /> __ Y 1,t- _��1 �,-�.�i-� <br /> ��, ��,,� �s�, -4 ���'�" o� O��l�TO <br /> � <br /> `�� r ,�„� � :� <br /> a <br /> �: 1�`"s.....t'v``"� �'�''+.e''�: <br /> rs-i���;. <br /> �;.-���� �:�. Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> _� Y,.un. <br /> "°;��:�T`� 'ii�`�". <br /> :j � _ A�� ', On the North Shore of Lake Minnetonka <br /> ��,y . <br /> DATA PRIVACY ADVISORY <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 or any of its departments may require <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> l. The inf ormation you f urni sh wi I 1 be used to determine your <br /> aual.ification 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 local, s�ate or <br /> federal agencies to the extent necessary to process the permit ar <br /> license. <br /> 4. If your requested permit or Iicense requires Councii act�or. <br /> to approve, some informaticn may become public. <br /> 5. You have certain rights under M.S. 13.04 to rev�ew private <br /> data on yourself. <br /> 6. Your full name is required to proc�ss this application or <br /> permit. <br /> .�--�„�,� / ► JA�'10 N-e, T� �1,H10r <br /> First Middle Last v <br /> a�y C�,sc� �f �� <br /> Address <br /> l,Jo. �a.�"�. 1(ln � � � 3`i I <br /> City State Zip <br /> ��1z� �� i - g ga.g <br /> Phone <br /> I understand my rights as stated above. <br /> �n,;..,_,P�._ �,,� „� - <br /> Signature � <br /> BUILDING&ZONING—473-7357 � ADMINISTRATION&FINANCE —�73-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />