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� + <br /> . � <br /> � � ��[�� o� ����T+t� <br /> - . post Office Box 66•Crystal Bay,Minaesota 5a323•Municipal Offices <br /> rt u' . <br /> i - <br /> On the North Shore of Lake Minrzetonka <br /> � - o ' o� <br /> DATA PRST7ACY A��SORY <br /> a Subd. 2, "Rights of subjects of <br /> Tn accordance with M.S• Z3�ou�that your request for a pe'-"mit or <br /> data" , we Would like �o inform Y of its departments may reauire <br /> ".icense from the City of Orono or any <br /> -7ou to furnish certain private cr coniidential inior.nation• <br /> vou are notified that: <br /> l. The iniormation you furnish will be used to dete'-"m'�e Your <br /> cuaiiF�ca�-on for the pe�:n=-� or Iicense requested- <br /> 2. you may ref us e to supp ly <br /> data, but resusal. may requi�e that <br /> the ermit ar license. <br /> tne City deny P . <br /> 3. The information may be snared w=th ot�oc sscthe Pe'-�1e °r <br /> f ederal. agencies to the extent necessary to p <br /> ?icense. , • <br /> yod pe*�it or license requires Counc�I. ac��o% <br /> a. �i your reques�.. become public. <br /> to aporove, some information may <br /> 5. You have ceYtain rights under M.S. 13. 04 to review griva�e <br /> data on yourself. <br /> 6 . Your full name is recuired to proc�ss this appl.ication or <br /> pe�it. <br /> .�-�,-� � - �.,t� �r-��'-P('u�¢'�j <br /> �� �� �• �'�� Las�. <br /> First Middle <br /> i <br /> Adcress <br /> c�� ,� � �l-I W l i�-, ���' <br /> State Z1r <br /> City <br /> �r Z� 3�. � - �z�� <br /> Phone <br /> I understand my rights as stated above. <br /> �(�-�-� � � . . <br /> S � gnature <br /> 'cJILD[NG&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 <br /> • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />