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� <br /> .,,� �y� <br /> . s3r '� �� <br /> '4. ������ C ITY of O1�ON� <br /> _�� , <br /> Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> 0 <br /> � . � � On the North Shore of Lake Minnetonka <br /> DATA PRNACY 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 reguest 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 wi3.1 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 local , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> 3.icense. <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 private <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> f1 KOR£cv -T�,E'S Sc �!�L T z- <br /> First Middle Last <br /> 3 �ro 4 E�3r � .���� fT <br /> Address <br /> �� Ro � � mN SS3S,� <br /> City State Zip <br /> �iyy- �g � 7 <br /> Phone <br /> I understand my rights as stated above. <br /> Signature . <br /> BUILDING&ZONING—473-7357 • ADMINISTRATIOIV&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />