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-.� <br /> --�=� <br /> - ="`�-=-----> <br /> ":ia. '-v'y yw i�'i.i.:i.�..��] <br /> , �� �.�..�...�D�� J_.. .��'� <br /> .....o......_ ... .�e'.,...:,,...� <br /> __' __'. _ .. _ _ <br /> ..�....�•w=�_.^�t_a�R'-`..�+! <br /> � � ` _� <br /> ��, ���� ��� ��'��' �D� ���1�T� <br /> � ��;,,;�R;��: ;;'� Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> �::��.-�,--.��,..:..:. <br /> - � lS 9 <br /> ��� '`� On the North Shore of Lake Minnetonka <br /> ', 'T�1 �r.. .:y <br /> DATA PRIVACY 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 /> l. The information you furnish wil.l 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 iocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> lic2nse. <br /> 4. If your requested permit or Iicense requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rignts under M:S. 13.04 to review pri�a�� <br /> data on yourself. <br /> 6. Your full nar,ze is requirec� to process this aoplication or <br /> permit. <br /> ��(A v � i� �2�-.r`��c ���2sc�,tif <br /> r i.z'st M�ddle Last <br /> �"L`ss� C��� c_�R--�l�c� f�l�" S ci <br /> Address <br /> ��` � �� � � ('�� rt�..i ��� 1 �� <br /> City State Zip <br /> �� ��'--��—��71 +'i uv"`� <br /> Phone � ` s - �7�`7 c�F-�c cv <br /> I understand my rights as stated above. <br /> � ����ti� <br /> Signat e <br /> BIJILDING&ZONING— 473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />