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� <br /> .� <br /> � o <br /> CITY of ORON <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> � � <br /> � � � � On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we would like to inform you that your request for a permit or <br /> license f rom 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 information may be shared with other Iocal, s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii ac��or. <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 to proc�ss this application or <br /> permit. <br /> �� <br /> D /`S / hE w <br /> First <br /> Middle Last <br /> / S,3S j;�,'�,h �'c .�v <br /> .Address ,/ <br /> • � �� � �� �S3�Y <br /> City State Zip <br /> �/ � / - ���3/ <br /> Phone <br /> I understand my right as stated above. <br /> / " <br /> i <br /> Signature ' <br /> BUILDING 8c ZONING-473-7357 • ADMINISTRAT[ON&FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSiNG <br />