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� - <br /> ,,:..� ,,. <br /> — �'4'.1 <br /> � � .i�'�, �xa,'� <br /> r t � <br /> +I t � �: <br /> � '` � C ITY of C1RON(� <br /> r`{ �f. .��:«r5 3� <br /> Y <br /> � y '. � � <br /> �!Y ```'' � �' Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> > ,�:,;,'� <br /> o ,��;`, i �'`9 <br /> �'�' " On the North Shore of Lake Minnetonka <br /> • O ��.,� . <br /> DATA PRNACY 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 /> license 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 license. <br /> 3. The information may be shared with other Iocal , state or <br /> federal agencies to the extent necessary to grocess the permit or <br /> license. <br /> 4. If your requested permit or I.icense requires Councii action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 Lo review pri�a�� <br /> data on yourself. <br /> E . Your full name is required to process this apt.Iica�icn or <br /> permit. <br /> > -- ,'` � <br /> � � � � �-- � � , <br /> ��r �l/( ��--- � l�;� l.� ! c �.,� < ti <br /> First Middle Last <br /> ( �� �� �; �t �j c L- !� ;�C 4' G; <br /> Address - <br /> / j- �r � ��f �„� ��L �f' Er��� / ���� �- <br /> City,� State Zip <br /> � � _ � �- �, <br /> _ � '� � � .� �',� � <br /> Phone <br /> I understand my rights as stated above. <br /> �_ � � : � � _�__._ - <br /> � � <br /> � ��,��.-r, � �,,� ��'L.����,,�._._.. <br /> S�ignature ` <br /> BUILDING&ZONING—473-73�7 • AD!NINISTRATION&FINA\CE—4;3-7358 • PUBL[C WORKS—473-7359 <br /> ASSESSII G <br />