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_ i � � <br /> � � NO <br /> CITY of OR� <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•MnniciPal Offi�es <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 erm t or <br /> � data", we would like to inform you that your request for a p <br /> license from 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 /> l. 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 reguire that <br /> the City deny the permit or license. <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 /> license. <br /> 4. If your requested permit or Iicense requires Councii act�or. <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your full name is required to proc�ss this application or <br /> it. <br /> � �L � �S <br /> First <br /> �� Middle . Last <br /> �6�5 l�o , � �;�-t a� � � <br /> Address <br /> �Gc�✓� � U"L� v �� l9Y <br /> City State Z1p <br /> �'1�- � � �� �O <br /> Phone <br /> I u tand my rights as stated above. <br /> Signature � � <br /> BUILDING&ZONING—473-7357 <br /> • ADMINISTRATION 8c FINANCE—473-7358 • PUBL[C WORKS—473-7359 <br /> ASSESSING <br />