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ryP,��I� <br /> ,f'..i �5£� <br /> �.. �� � <br /> �y ' � � �� C ITY of ORONO <br /> F . <br /> �`�{����� � Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> � � <br /> b'��1 �,� <br /> k�"`� ""� �'`�'" `` On the North Shore of Lake Minnetonka <br /> � �. ' �x, <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04 , Subd. 2, "Rights of subjects of <br /> data", we would 3ike 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 wi31 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 local , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Councii act�or. <br /> to approve, some information 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 process this application or <br /> permit. <br /> ���:( (� ij � f� � r s i L� - <br /> First Middle Last <br /> �> c Zc 1�: .3 3 <br /> Address <br /> � �' 1a �i �� ►�r1 /1�� � 53 �-� -- <br /> City State Zip <br /> ��--1 ?f - 3 �l �� � - <br /> Phone <br /> I understand my rights as stated above. <br /> ��� � .�� <br /> Sig a ure . <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />