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. � � _ <br /> f <br /> �_`,j::y... � <br /> �.:��. ��. C ITY of ORO�TO <br /> Post Office Box 66•Crystai Bay,Minneaota 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 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 license. <br /> 3. The information may be shared with other Iocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�� <br /> data on yourself. <br /> E. Your full name is required to process this application or <br /> permit. <br /> . <br /> � �G.�y � �� �� ►�s�%�� <br /> ���`� <br /> First Middle Last <br /> Z_�2 � '� t `�V�L� ,''S 4: �� <br /> Address <br /> ��`� �av ► r�i ,�� -��i v � <br /> City State Zip <br /> l'� y�� ? �'' _` �j-�� <br /> Phone <br /> I understand my rights as stated above. <br /> � <br /> � - -_ - � ,�.-- � y �� <br /> � � �.� <br /> <. <br /> Signature � <br /> BUILDING&ZONING—473-7357 • ADbtIMSTRATION&FINANCE—473-7358 � PUBI,IC WORKS —473-7359 <br /> ASSESSIti G <br />