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.� <br /> c <br /> � � ����� <br /> C�'�'� o . <br /> Post Office Box 66•Crystal Bay.Minnesota 55323•Municipal Qffices <br /> ! <br /> � _ � � On the North Shore of Lake Minrcetonka _ <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of sub er�� Q� <br /> data", we w o u l d l i k e t o i n f o r m you thof itsrdeeart en t rma y r e q u i r e <br /> l i c e n s e f rom the City of Orono or any P <br /> you to furnish certain private or confi den tia l in f o r i n a t i o n. <br /> You are notified that: <br /> l. The infor fo ltheypermit or li ensebreque ted, determine your <br /> qual.ification <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared witht�oth=�r eSscthe perntit or <br /> federal agencies to the extent necessary P <br /> 3.icense. <br /> 4. If your requested permit or license requires Councii ac�ior. <br /> to aporove, some information may become public. � <br /> �. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your full name is required to proc�ss this application or <br /> pe*mit. <br /> � Q� � � \i v` <br /> Fir l iddle <br /> ��p �v�� � � <br /> 'dre s <br /> � � - � <br /> City State Zi <br /> � <br /> Phone <br /> I understand m g s stated - <br /> Signature � ' � <br /> BUILDING&ZONING—473-7357 • ADMINISTRATIOiV&FINANCE—4�3-7358 <br /> • PUBLIC WORKS—473 7359 <br /> pSSESSING <br />