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� � <br /> ..,.�..�,..�.= <br /> x�,��w..r ��V�� <br /> ���"µ � � <br /> :��.� ��'�` O <br /> � f�:. <br /> � :��: <br /> ����:=: <br /> ��,�� <br /> „�y� Post Office Box 6Fi•Crystal Bay,Minnesota 55323•Municipal Offices <br /> : • <br /> 4 `�-- <br /> � _ � � On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVIS�RY <br /> In accardance with .M.S. 13.04 , Subd. 2, "Rights of sub e��t or <br /> data"; we would like to .info�m you. tha.t your request for a p <br /> license from the City of Orono or any of its d�epartments 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 /> qual.ification for the permit or Iicense requested. <br /> 2. You� may refuse to supply data, bu� refusal may ,require that <br /> � the City deny the permit or Ii.cense. <br /> 3. The information may be snared with other Iocal , s`ate 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. ac�io% <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 yoursel.f. <br /> 6, Your full name is required to process this application or <br /> permit. <br /> �r � � �� r ,�t, �` <br /> Middle Last <br /> First . . <br /> l � �.5 ���.� � 1 da.� �� . , � . i <br /> Address � <br /> �a� 7- ��• 3� i <br /> City State Zip <br /> �7�3 �3� �I ' <br /> Phone � <br /> I understand my rights as stated above. <br /> c <br /> Signa ure <br /> , <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—�73-7358 <br /> • PUBLIC WORKS—473-7359 <br /> ASSESSING ! <br />