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� <br /> � � ��['��' o� ���Ii�'O <br /> M <br /> Post Office Box 6&•Crystal Bay,Minaesota 5��•Municipal Offices <br /> � On the North Shore of Lake Minnetonka - <br /> • ' • • <br /> DATA PRIV'ACY AD�SORY <br /> ermit or <br /> In accordance with M.S. 13•ou'that your request for a P�ects1=e <br /> we wou l d l i k e t o i n f o r m Y of its depar t m e n t s m a y r e Q u <br /> data", of Orono or any <br /> licease from the City rivate or confidential information. <br /> you to furnish certain p <br /> You are notified that: <br /> 1, The information you furn�ir li ensebrequested, determine your <br /> ermit <br /> qualification for the p require that <br /> 2, You may refuse to supply data, but refusal may <br /> the City deny the permit or license. <br /> 3. The information may be shared Witht�° p=o�e scthe permit or <br /> f ederal agencies to the extent necessary <br /> ?icense. <br /> d, If your requested perir�it or Iicense requires Councii ac��or_ <br /> to app=pVe, some information may become public. <br /> �, You have certain rights under M.S. 13.Oa to review private <br /> data on yourself. <br /> 6, Your full name is required to process this application or <br /> per,nit. <br /> . ����-1� �:l �Gvl h'1/�Z <br /> �� Middle Last <br /> First <br /> � �� � ��� � <br /> Addres s ��ga 6 <br /> 1S �'� � <br /> City <br /> State Zip <br /> 72�1� ��� . <br /> Phone <br /> I understand my rights as stated above. <br /> � - <br /> Signature <br /> � • PUBLIC WORKS—473 7359 <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FiNANCE—473-7358 <br /> ASSESSING <br />