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� <br /> f <br /> ���J ' <br /> -k4 � <br /> f: <br /> f 1�t3 '7v,F'-�. <br /> ' ��� r � � C ITY o� OROl�TO <br /> �� � . �t <br /> � <br /> k �j� �� <br /> }� y,, <br /> +' " y�, �; ' ,.,;,: Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> ',±,�r <br /> �', a� ;� <br /> • _ � � On the North Shore of Lake Minnetonka <br /> DATA PRIVACY AD�TISORY <br /> In accordance with M.S. 13.04 , Subd. 2 , "Rights of subjects of <br /> data", we would 3ike 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 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 informatian may be shared with other iocal , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or I.icense requires Councii act�on <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�e <br /> data on yourself. <br /> 6 . Your full name is required �o process thi.s applicaticn or <br /> permit. <br /> �% �� c_ �— C� ,� ( �� �f/� <br /> First Middle La t <br /> � � 4 �� ���,r, e�s�--r f� �lJ l.�(�— <br /> Address <br /> �S-3 �i � <br /> � r �� �'" ���r'V — <br /> City � State Zip <br /> �t ��� ��� � <br /> Phone <br /> I understand my rights as stated above. <br /> ` � �� � <br /> Signat e <br /> BUILDItiG&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br /> � <br />