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_� _ <br /> `- � � ��'��' o� ���I�TO <br /> M! <br /> . Post Office Box 6b•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • - <br /> On the North Shore of Lake Minneton a <br /> • - • � <br /> DATA PRIVACY AD�SORY <br /> "Ri hts af subjects of <br /> a Subd. 2. g ermit or <br /> In accordance with M.S. 13-ou�tnat your request for a p <br /> data" , We Would like to inform y of its departments may require <br /> license from the City oi Orono or any <br /> you to s"urnish certain private or confidential inrormation. <br /> you are notified that: <br /> 1, The iniormation you furnish will be used to determine your <br /> aualification for the pe'-�i` �r Zicense requested• <br /> 2. You may refuse to supply data, but refusal may require that <br /> tne City deny the permit or license. <br /> be snared with other 1oca1 , s�ate or <br /> 3 . The information may rocess the pe*-mi� or <br /> f ederal agencies to the extent necessary to p <br /> license. <br /> d. �i your requested per:nit or <br /> iicense requ�res Councii ac��on <br /> +o zpprove, some inLormation may become public. <br /> ` You have certain rights under M.S. 13_Oa to rev�ew �riv��e <br /> J � <br /> data on yourself. , <br /> �- �ss tzis 3DD1-�cat_or. or <br /> 6 . Your full name is reauired �o proc_ - <br /> pe�it. <br /> �� � �l�l�C� <br /> �Y� lf�� zzs� <br /> First Middle <br /> `�7-3 � � ���-,� ��t <br /> _ � � �Address � /,� � �/� -� <br /> � � ✓ <br /> ' �'�����ti�� � z�� <br /> State <br /> City <br /> � � � l � �t ( <br /> � <br /> Phone � <br /> ri hts as stated '� ove. <br /> I understand my 9 . <br /> Signature <br /> � ADMINISTRAT�ON&FiNANCE—-t73-�358 <br /> • PUBLIC WORKS—473-7359 <br /> BUILD[NG&ZO`lING—473-7357 <br /> ASSESSIN G <br />