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� <br /> � <br /> CIT�' of ORON� <br /> Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Officea <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 license 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 /> license. <br /> 4. If your requested permit or Iicense requires Councii action <br /> to approve, some information may become pub3ic. <br /> 5. You have certain rights under M.S. 13.04 to review prica�e <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> � <br /> ., <br /> ��� ,� � �--� � �� �' � ;�-�;{ �_ � p,,�/�. <br /> First Middle Last <br /> -1`�._�� � ,_).� �. ��;.�, �.4.. ' y.� �- t.� • /��� C ��� <br /> � <br /> Address <br /> � C �t ��`. / �- % ��- � � �/6� <br /> l � ' � <br /> . <br /> City State Zip <br /> `� -� / _ - -' - „ � <br /> � , � <br /> Phone <br /> I understand my ri hts as stated above. <br /> ,---,.� � ' <br /> _ .�__ _ -- <br /> _ _._ <br /> �. <br /> - � . --- <br /> Signature,.� _ _ __--- <br /> �_,. <br /> BUILDING&ZONING—473-7357 • ADMINISTRATtON&FINAIVCE—473-7358 � PUBLIC WORKS—473-7359 <br /> ASSESSING <br />