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. � <br /> ���y'� � , . <br /> � <br /> r t :� <br /> � " �i��� O� ����� <br /> � <br /> t �-k�� r r��'{� x <br /> . � <br /> �y i � � Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> ; <br /> 05 .�� � fi.{; � <br /> `" �" "' '� On the North Shore of Lake Minnetonka <br /> Y .. <br /> . � .'y t�d� L°a.: <br /> ��sf,'q,?F,`.�I <br /> ,� <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 wil.I 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 , 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 Counci� action <br /> to approve, some information may become public. <br /> 5. You have certain rights nnder M.S. 13.04 to review pri�a�� <br /> data on yourself. <br /> 6. Yaur full name is required to process this applica�icn or <br /> permit. <br /> � � �� <br /> � � � �� <� ��Il � � �, ��� <br /> �>/.�d) 1(�� ' C l C' <br /> First Mi` dle Last <br /> ,�� .. ,--- <br /> � -� t% �JC�� �� �� `> j ,� <br /> Address <br /> '1 ,;� t, �- �- `i f��' ��i S `�' ,'I `"� �� �/ �'� <br /> City State Zip <br /> ; �< 7 — `� "� � _��,� ��-... <br /> Phone <br /> I understand my rights as stated above. <br /> �� � ./�� � � ' <br /> ,L,�- �� F L � <br /> ignature ; <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FIN.1tiCE—�73-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />