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t� <br /> � ����� ����� <br /> � <br /> Post Office Box 66•Crystal Bay,Minnesota 5532:3•Muaicipal O�cas <br /> ! <br /> � _ � � On the North Shore of Lake Minnetonka _ <br /> DATA PRIVACY ADVIS�RY <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 /> 1. The informati�hey�erm tnor licensebrequested. determine your <br /> qualification for P <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The informat�io the extenthnecessaryhto processcthe permit or <br /> federal agencies <br /> I.icense. <br /> 4. If your requested permit or Iicense recxu�res Counci3. ac�ior. <br /> to approve, some information may become public. <br /> �. You have certain rights under M.S. 13.04 to rev=ew private <br /> data on yourself. <br /> 6, Your full name is required to proc�ss this appl.ication or <br /> permit. <br /> 1Jan 4- h�sa�o �,�1���a- <br /> First <br /> Middle Last <br /> 3P�Coc� �U 5 ��c �c <br /> Address <br /> Jv <br /> City <br /> State Zip <br /> ���-���a . <br /> Phone <br /> I understand my rights as stated above. <br /> � � � 4� ��-�--� - <br /> Signature � � � <br /> BUILD[NG&ZONING—473-7357 � ADMINISTRATiOiV dc FINANCE—473-7358 <br /> • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />