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,��� <br />' w "�+�,r = �,'�j��,�.,r� <br /> �a� � <br /> � � r`���.�-�- ; ���� � Ci��� O� ����� <br /> , � ����u :�; <br /> ?��'�x, Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> �;:��W,�Y..:r��o <br /> � _ � e On the Nortlz 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 /> l.icense 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 Iicense. <br /> 3. The information may be shared with other �ocal , 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 Councii. 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 /> 6. Your full name is required to process this applicatian or <br /> permit. <br /> ���cs� � � ����' �1 <br /> First Middle Last <br /> �� � F� �� '1 ��� � ��ce � �f� — <br /> Address <br /> 1 ,/ — �, <br /> ����Ce� 1 '�l �[ �'( l�l �� .� 1 I <br /> Cit—y ` State Zip <br /> ��7,��� ��I/ �' <br /> Phone <br /> I understand my rights as stated above. <br /> / <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />