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� <br /> �i��� O� ����� <br /> Post Office Box 66�Crystal Bay,Minnesota 55323•Municipal Offices <br /> _. a <br /> � - • � On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subject�s of <br /> data", we would 3ike to inform you that your request for a permit or <br /> license f rom the City of Orono or any of its departments may requ�re <br /> you to furnish certain private or confidential information. <br /> Y'ou are notified that: <br /> 1. The information you furnish wi3.l 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 license. <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 /> license. <br /> 4. If your requested permit or Iicense requires Councii ac��or. <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 /> K��v,u�l'� G D�RR <br /> First Middle Last <br /> �83o G��r6A�� Ro�� <br /> Address <br /> �IN�u�TB�KA- ti1�rJ. �"'S��s <br /> City State Zip <br /> �'3�--7�Sq <br /> Phone <br /> I understand �my rights as stated above. <br /> � <br /> , <br /> -, � � <br /> �����;z,: ��-t�� _ = �.�_ � ��.... <br /> Signature <br /> BUILDING&ZONING-473-7357 • ADM1NlSTRATION&FINANCE -473-7358 • PUBLIC WORKS -473-7359 <br /> ASSESSIN G <br />