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� <br /> s;. <br /> £ CITY of OR011eTTO <br /> Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> • <br /> � - � � 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 Iike 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 wil.l 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 license. <br /> 3. The information may be shared with other local , 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 Councii a�tion <br /> to approve, some information may become public. <br /> 5. You have certain rights ander M.S. 13.04 to review pri�ate <br /> data on yourself. <br /> 6. Yaur full name is required to process this apFlicaticn or <br /> permit. <br /> �I GZ`��'CG�✓l� �/�CtV"r C �C��_%��� ��� _ <br /> First Middle Last <br /> , <br /> �. <br /> f l��l�`� � �-�r�t-�� I'-��� ��"`-� _ <br /> Address <br /> �un c� � �;�,�,� Gt,lilJ .���S� <br /> City State Zip <br /> y 7C�- l l l��i <br /> Phone <br /> I understand my rights as stated above. <br /> _--- <br /> � /�. /c l�v' <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />