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k`;. <br /> :��k CITY of OR4N0 <br /> ;. <br /> Post Office Box 66•Crystal Bay,Minneaota 55323•Municipal Officea <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 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 /> 1. The information you furnish will be used to determine your <br /> qualification 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 Iicense. <br /> 3. The information may be shared with other Iocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense reguires Counci3. action <br /> to approve, some information may become publ.ic. <br /> 5. You have certain rights under M.S. 13.04 to review prica�� <br /> data on yourself. <br /> 6. Your full name is required to process this apFlication or <br /> permit. <br /> .� r w;,�. �� ��. C��� <br /> ' First iddle Last <br /> � %��� �SC-c1 f�i�J`� K�Jk <br /> Address <br /> �i�Ll�'�, /��� �5� ✓� <br /> City State Zip <br /> ��% - �� �� � � <br /> Phone <br /> I understand my rights as stated above. <br /> ,,, <br /> _ ��'i.�.v ,/�/�Z.t;��c� <br /> Signature � <br /> BU1LDIiJG&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSES5ING <br />