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_^ +� <br /> ��,.�. <br /> ;`'"�'`� - <br /> ������� NO <br /> �.;.� �� - CITY of ORO <br /> ��;, <br /> �:� <br /> ,::� Post Office Box 66•Crystal Bay,Minnesota 55323•MuniaP���� <br /> f <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 Iike to inform you that your request for a permit or <br /> license from the City of Orono or any of its departments may require <br /> you to furnish certain private or confidential i.nformation. <br /> You are notified that: <br /> 1. The information you furnish wil.l be used to determine your <br /> qualification for the permit or Iicense 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 oth��r e scthe permit or <br /> federal. agencies to the extent necessary to p <br /> license. <br /> 4. If your requested permit or license requires Councii ac�io% <br /> to approve, some information may become pubZic. <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 /> permit. <br /> � ���;\;C�S�� <br /> '�' �'� � Last <br /> First Middle <br /> '� `��Cj � c�,a���. � c -{v� <br /> Addrsss <br /> � �. :� � C '�`- <br /> �`� e ,.. _ <br /> Cit State Zip <br /> ����l���`�"��°� <br /> Phone <br /> I understand my rights as stated above. <br /> � -��--� <br /> v < �Z. 1 _ <br /> Signature <br /> BUILDING&ZON[NG—473-7357 • ADMINISTRATION&FINANCE—473-7358 <br /> • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />