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� <br /> t;�,� <br /> �"�+Y.,. 1",��� ,w <br /> ��� �9. <br /> � ��� � �i��� O� ����� <br /> � <br /> � <br /> ,����;���� ����:. <br /> Hw��ge'�' Y�_�,.. �. <br /> � � "`"�" Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> • <br /> � - v � 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 3ike to inform you that your request for a permit or <br /> Iicense 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 suppl.y data, but refusal may require that <br /> the City deny the permit or 3icense. <br /> 3. The information may be shared with other Iocal , state or <br /> federal agencies to the extent necessary to grocess the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Counci� action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 �o review pri�a�� <br /> data on yourself. <br /> E. Yaur full name is required to process this apr,lica�icn or <br /> permit. <br /> ���t�s ����,e �u�-.z ,� <br /> First Middle Last <br /> �''�� ����7-- r���e.�-�s ,� �� <br /> A�ddress <br /> ,���.u� �� �S3 G� <br /> City State Zip <br /> �7� �� � � <br /> Phone <br /> I understand my rights as stated above. <br /> Si ature <br /> BUILD1tiG&ZOMNG—473-7357 • ADMIlVISTRATION&FI:VANCE —473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIti G <br />