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� <br /> � I <br /> � <br /> CITY of OliONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> � _ � � On the North Shore of Lake Minnetonka <br /> DATA PRNACX ADVISORY <br /> In accordance with M.S. 13.04, Subd. Z, "Rights of sub e��t or <br /> data", we would 3ike to inform you that your request for a p <br /> license 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 license requested. <br /> 2. You may refuse to suppl.y data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The inf ormation may ben�hneces aryhto processcthe permit or <br /> federal agencies to the exte <br /> license. <br /> 4. If your requested permit or license 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 ful.l name is required to proc�ss this application or <br /> permit. <br /> j���.b s.ti�` /s, ��1����./ <br /> First Middle Last <br /> � � � <br /> �s s�� � �.� <br /> Address <br /> �1/l 7✓l�� /�t�1 v�/ ���� �l�- <br /> City State Zip <br /> ��� � �?3�- 33� � <br /> Phone <br /> I understand my rights as stated above. <br /> . t <br /> Signature � ' <br /> BUILDING&ZONING—473-7357 • ADMIIVISTRATiON&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />