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i <br /> i <br /> i ,,_., _ . <br /> � <br /> CI'�Y of ORONO <br /> Po t Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> � <br /> � _ � � On the North S ore 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 hat 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 co fidential information. <br /> You are notified that: <br /> 1. The information you furnis will be used to determine your <br /> qualification for the permit or Iicense requested. <br /> 2. You may refuse to supply d ta, but refusal may require that <br /> the City deny the permit or lic nse. <br /> 3. The inf ormation may b en�h eces aryhto processcthe permit or <br /> federal agencies to the ext <br /> license. <br /> 4. If your requested permit o license requires Councii ac�ior. <br /> to approve, some information ma become public. <br /> �. You have certain rights u der M.S. 13.04 to review priva�e <br /> data on yourself. <br /> 6. Your full name is require to procass this application or <br /> � <br /> permit. " <br /> 6__�` `"'� ' Last <br /> First Middle <br /> 3D <br /> Address <br /> �CY� r� �J�� <br /> City State Zip <br /> -�aa --�ia <br /> Phone <br /> I understand my rights as stat d above. <br /> Signature � <br /> BUILDING&ZONING-473-7357 • ADMINISTRATION FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSiNG ' <br />