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�= � C���i' o� ���I�TO <br /> � y,�� Post Office Box 66•Crystal Bay,Minnesota 55323•Munir_ipal Offices <br /> � <br /> • - • • <br /> On the North Shore of�ake Minnetonka _ <br /> DATA PRNACY ADVISORY <br /> In accordance with M.S. 13.04 , Subd. 2, "Rights of subjects of <br /> we would like to inform you that your request for a permit or <br /> data", of its de artments may require <br /> license from the City of Orono or any P <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish wil.l be used to determine your <br /> cruaiification for the permit or license 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 inf ormat�o the ext entnnecessaryhto processcthe permit or <br /> f ederal agencies <br /> license. <br /> a. If your requested permit or license requires Councii. ac�'-or- <br /> to aporove, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6 . Your ful.l name is required to process this application or <br /> pe*-�it. <br /> First <br /> Middle Last <br /> Address <br /> Ci`y State Zip <br /> Phone <br /> I understand my rights as stated above. <br /> Signature � <br /> BUILDING&ZONING—473-7357 • ADMINISTRAT70N&FINANCE—473-7358 <br /> • PUBLIC WORKS—473-7359 <br /> ASSESSING . <br />