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� - �" <br /> � <br /> C ITY of ORONO <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 sub e�� t or <br /> data", we would like to inform you that your request for a P require <br /> license f rom the City of Orono or any of its departments may <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The in'on forltheypermit or licensebrequested. determine your <br /> qualificats. <br /> 2. You may refuse to supply data, but refusal may reguire that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with other local, s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> I.icense. <br /> 4. If your requested permit or Iicense requires Counci3 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 procass this application or <br /> permit. <br /> �'i�liT � ��D�/�sa�.J <br /> First <br /> Middle Last <br /> 'f s rn�lR.r��.�c�a a� af+l� <br /> Address <br /> - ORa�o M,J 5�39� <br /> City State Zip <br /> ��S- 3z�-3 <br /> Phone <br /> I understand my rights as stated above. <br /> Signature ' <br /> BUILDING&ZONING—473-7357 • ADMINISTRAT[ON�c FINAIYCE—473-7358 <br /> • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />