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,. ` ��yF:�' • `. <br /> „��i� xk.a ' :u <br /> � � � <br /> � �' C ITY of OI�Ol�� <br /> �. <br /> �, ,�. i ,. a <br /> a!� 7 f r <br /> ! <br /> `t b � Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Officea <br /> ' .3"'"' ;`�• <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 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 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 �ocal , sta.te or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or I.icense requires Councii a�tion <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. Yaur full name is required to process this application o� <br /> permit. <br /> �� � <br /> First Middle Last <br /> 3 '� yS C'�.ST-�--c- ��T_�� <br /> Address <br /> (��ii Z� �I� . �s'3�'/ - <br /> City State ZiP <br /> y7�- ��� � <br /> Phone <br /> I understand my rights as stated above. <br /> LU . <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING ° <br />