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u � <br /> ,t„ r� <br /> .� �'������"�� � ' ._ . <br /> � ��t���! CITY of ORONO <br /> �� <br /> Post Office Box 66•Crystal Bay,Minneaota 55323•Municipal Offices <br /> • <br /> s - s � 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 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�at� <br /> data on yourself. <br /> 6. Your ful.l name is required to process this applicatian or <br /> permit. <br /> �..;; �"�'`�' i�'"� r� l�'1 �``Cc Ct <br /> First Middle Last <br /> �, � � , i <br /> � � -� R� � � ��� �oi <br /> Address <br /> �G %; r��/ / �ii / i� /'7'�/ ' � �� -�S/ / <br /> City State Zip <br /> `� � � �-.�1 � <br /> Phone <br /> I understand my rights as stated above. <br /> �� <br /> Signatur <br /> BUILDING&ZONING-473-7357 • ADMIN[STRATION&FINANCE-473-7358 • PUBLIC WORKS -473-7359 <br /> ASSESSING <br />