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- . � <br /> ����y� <br /> ��' �� � - <br /> r;..��;•�a ,,. <br /> r;�.s� �, ��+e �- <br /> �`�j��ti� '�-»�;sa��` � <br /> ����-=�� �� �:� �i��� O� ���� <br /> , , , �� � <br /> 6 � Y�Y�r r �`�`.� <br /> ��r.w�� Z"'7�r.f. <br /> �y�A ,,,; Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> �s,'_;5:. <br /> • " , � <br /> � _ � �Y��• 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 /> l. 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 , 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�ior. <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 proc�ss this application or <br /> permit. <br /> �r���c�k�5 �c��,,�of-c,. v �c:/1/�1���� <br /> First Middle Last <br /> � �o � c ��s c� ` �% <br /> Ad ress <br /> 5�-- c,����� 5 �i� �1� �5 �// � <br /> City State Zip <br /> �� 3_ �-� y�, <br /> Phone <br /> I understand my rights as st �ed above. <br /> � �-z <br /> Si ature . <br /> � <br /> BUILDING& ZONING—473-7357 <br /> • ADMINISTRATION& FINANCE—�373-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />