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!� <br /> �. • :a,"4+r,. <br /> . �e <br /> .�� �<<< <br /> A ,,-�a �a � <br /> d � CIT�' of O�OI�TO <br /> ey— � <br /> f.' <br /> 's qR0'�r '�t 'i sJr'h��ky4��? .. <br /> � -i5. `yTi+ b'4�,'a"� <br /> 4?�;c:'+'.r.'Wae,v$e,��., <br /> ;�'�a �` " Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Officea <br /> y.. <br /> � <br /> � � - � W �; On tlze Nortlt 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 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 Iicense 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 , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <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 pri�a�e <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> Ul/i�//r��/ /L S`a�� <br /> First Middle Last <br /> ` ��� �,�/� :�1 <br /> Address <br /> �ON G�y jC�i-' i��/�/, S 3S L <br /> Ci State Zip <br /> �'73- �?y�d <br /> Phone <br /> 2 understand my rights as stated above. <br /> r <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 � PUBLIC WORKS —473-7359 <br /> ASSESSING <br />