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00iO4i94 09:57 THE CITY OF ORONO 612-473-7357 003 <br /> � <br /> C�'��' O� O��NO <br /> ~ Post Office Boz 56•Cryseai Bay,Minnesota 55323•Munidpal OEScea <br /> • <br /> a. • � � On the North Shore oj Lakc Minnctorska <br /> DATA PRIVACF ADVISORY <br /> In accordance wi,th M.S. i3.04, Subd. 2, "Rights of subj�cts of <br /> data"� we would like to inform you that your request for a permit or <br /> license from the City of Orono or any of its departments may require <br /> you to Purrtish certain pri vate or confidentiaZ information. <br /> You are notified that: <br /> l. The information you furnish KiZI be used to determine your <br /> qu�Iification for the permit or Iicense requested. <br /> 2. You may �efuse to supply data, but refusal tt►ay require th�t <br /> the Cit�► deny the permit or licertae. <br /> 3. The infarmation may be shared with other local, state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or license requires Council action <br /> to approve, some infermation may become public. � <br /> 5. You have certain rights under M.S. i3.04 to review private <br /> data on yourself. <br /> fi. Your full name is required to process this application or <br /> permit. \ �� <br /> tY�argare-4- �Pe�q y�� c,�►�ne 5 <br /> `T�n.or�s �ober-F <br /> First Middle Last <br /> i�Ss G1��r� �' I <br /> Address <br /> ��n.o r� n� ��3(�� <br /> -� State zf P <br /> City <br /> , �� � '- �� �C� <br /> Phone <br /> I understand my rights as stated tebove. <br /> Si nat e . <br /> BUILDING d�ZON{N�—473-7357 • ADMIN157'RnT70N dc PINAiYCL• —47�•7358 • PUiSL1C N'ORKS—�73•7359 <br /> ,4SSESSiNG <br />