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' _s <br /> -� � ����' o� ����T(� <br /> ..I i <br /> Post Office Box 66•CrYstal Bay,Minaesota 5�323•Municipal Offices <br /> a _ <br /> On the 1Vorth Shore of Lake Minrr.8tonka <br /> •)- • •' <br /> DATA PRSVACY A��SORY <br /> Subd. 2, "Righzs of subjects of <br /> �h M.S. 13-ou�that your request for a permit or <br /> Zn accordance wi�.- <br /> ciata" , we would like �o inform Y of its departments may require <br /> iicense from the City of Orono or any � � n=o�ation. <br /> you to �urnish certain private or consident_a1 <br /> v rA notified that: <br /> Q LI a...- <br /> rnish wiil be used to dezermine your <br /> 1, The inzormation you fu_ <br /> aualification for the pe rnit or license requested. <br /> 2. You may <br /> refuse to supDly data, but rerusal may require that <br /> t'rne City deny the oer*nit or Iicense. <br /> 3 . The information may be snared with ot:7�r Iocal , s�a�e or <br /> to roc�ss the pe�1� °i <br /> f ederal agencies to the exzent necessary P <br /> license. , <br /> d. �i your recuested pe'--�nz� or <br /> �icense requ�.res Counc�.I. ac��or_ <br /> �o zpprove, some in=or_nat�on �ay become publ�c. <br /> _„ You have certain rights under M•S- <br /> 13.Oa to rev�ew IIL"1Vc�e <br /> data on yourself. <br /> 6 . Your full. name is required to procsss this applicatio:. or <br /> pe�it. <br /> �--- <br /> � � j��-��;�-� <br /> �j �-���.�,� �,.J�:,: :_I�� Last <br /> _ *�;��=�_P <br /> r irst <br /> ��, �, �=2-�<� ����-� L�:K� <br /> Address > <br /> r� � `'.___�� � � / <br /> �..- k"C��s�c,. p <br /> �" Z i <br /> City <br /> State <br /> !� �7/C'9i� �✓ ����- �?_3i — <br /> Phone <br /> I understand my rights as stated above. <br /> �_ ���-� � � . <br /> Signature <br /> eUILD[NG&ZO`rING—473-�357 • ADMINISTRATION&FiNANCE—473-7358 <br /> • PUBLIC WORKS—4�3-�359 <br /> ASSESSIyG <br />