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. <br /> � <br /> CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323�Municipal Offices <br /> � <br /> � - � r 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 like to inform you that your request for a permit or <br /> Iicense 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 require 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�on <br /> to approve, some information may become public. <br /> �. 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 process this application or <br /> permit. <br /> L /�/ G Gt�--�� (� l��5% � <br /> Firs Middle Last <br /> ?��1� � /��-►.� S1� o ✓� �✓��� _ <br /> Address <br /> yyi�,�� /1��/ �5 3� y <br /> City State Zip <br /> ��� �/ �� <br /> Phone <br /> I understand my ri ts as stated above. <br /> � ' • <br /> Signat re <br /> BUILDiNG&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />