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� �r�' � , <br /> ""�•T �r�'', ,�zr` <br /> �'• �:�a• ", <br /> a ��, - <br /> j �� .i <br /> ���'�� � ��h CITY of OROI\TO <br /> rk�`= '�� ;:� <br /> �.� . L :r <br /> r b.�+•1.W�:.�' <br /> '�' ``' '�'��€ Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> • <br /> � - � s 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 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 process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Councii action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�� <br /> data on yourself. <br /> 6. Your full name is required to process this apt,Iicatian or <br /> permit. <br /> ' _ ,/� <br /> / � � �� <br /> First Middle Last <br /> � �l_�/ L� (� �7 � `-'"/' <br /> Address � <br /> ���- � (����r^ /��� �� � � <br /> City State Zip <br /> ����_ ��� � <br /> Phone <br /> I understand my ' hts as stated above. <br /> � <br /> �. <br /> S i g a tur e --�--� <br /> /'.. <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 � PU&LIC WORKS —473-7359 <br /> ASSESSING <br />