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. '� - - � <br /> .. � ' . <br /> � " _ _ <br /> � (�ITY of ORONO <br /> . Poat Office Box 66•Crystal Bay,Minnesota 55323•Municipal Officea <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 subjects of <br /> data", we would like to inform you that your request for a permit or <br /> license f rom 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 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 Iocal, state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or license requires Council action <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 process this application or <br /> permit. <br /> �-�44�.T � �M�4-.����c� !���L/vt P . <br /> First Middle Last <br /> ��'�—C�J� �c�� �Lt/� <br /> Address <br /> .� ��� <br /> City State Zip <br /> ��- ��� - <br /> Phone _ _ ' � <br /> I understand my rights as stated above. <br /> Signature <br /> BUILDING&ZONING—473-7357 � ADMIlVISTRATION 8c FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />